502701119-3-29-2022-27-AS-SHUT-CCYL26-20220329082150

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701119
Report Date: 03/01/2022
Date Signed: 03/29/2022 08:21:59 AM

Document Has Been Signed on 03/29/2022 08:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	ELEGANT CARE ASSISTED LIVING FACILITY		FACILITY NUMBER:	502701119
ADMINISTRATOR:	BHINDER, JAGTAR S		FACILITY TYPE:	740
ADDRESS:	2108 DOS PASSOS WAY		TELEPHONE:	(209) 665-5121
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	6	CENSUS: 0	DATE:	03/01/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Applicant, Jagtar Bhinder		TIME COMPLETED:	12:45 PM

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Licensing Program Analyst (LPA) Sarah Hurt conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA arrived and was granted entry to the facility by Applicant, Jagtar Bhinder. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Unit (CAU) on 10/08/2021 for a capacity of five non-ambulatory, and one ambulatory residents.

LPA Hurt observed the following:
Structure:
Facility is a one story house with 4 resident bedrooms, 3 bathrooms, family / living room, dining area and kitchen. The resident bedrooms will accommodate residents' furnishings.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Residents:
Bedrooms #1-4 will accommodate 5 non ambulatory and 1 ambulatory residents.
Bathrooms:
All bathrooms have a working toilet, wash basin, and walk-in/shower.
Linens and Hygiene Supplies:
Adequate supply of linens is stored in hallway closet.
Emergency Phone Numbers, Exit Plan, and Sample Menu:
Will be posted and readily available for review in the living room.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ELEGANT CARE ASSISTED LIVING FACILITY	FACILITY NUMBER: 502701119
	VISIT DATE: 03/01/2022

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Food Service:
LPA did NOT observe adequate supply of 7-day non-perishable and 2 day perishables would be stored in the kitchen and pantry.
Smoke and Carbon Monoxide Detectors:
Smoke and carbon monoxide alert systems were hardwired and found operational.
Fire Extinguisher:
1 Fully charged and stored by the kitchen and in the hallway.
Fire Clearance:
Approved on 12/15/2021
Appliances:
Electric four burner stove with oven, refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer are located in the laundry room next to kitchen and were clean and noted to be operational.
Toxins:
Will be locked and stored in laundry area above washer and dryer.
Water Temperature:
Tested and recorded at 117 degrees (within regulation range)
Medications, First Aid Kit & Manual:
First Aid kit with guide will be stored next to kitchen. Medication will be stored and locked in kitchen.
Resident and Staff Files:
Records will be kept in medication cabinet.
Reading Material, Games, Equipment, & Materials:
The facility has materials that commensurate with their plan of operation.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ELEGANT CARE ASSISTED LIVING FACILITY	FACILITY NUMBER: 502701119
	VISIT DATE: 03/01/2022

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The following items need to be corrected before the facility can become licensed:
.Resident bedrooms do not have 8 cubic feet of storage space.
Facility does not have adequate food supply of 7-day non-perishable and 2 day perishables.

Applicant will notify LPA of completion of the above items.

The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Unit.

Applicant was reminded of the statute that requires notification to Licensing Program Analyst within 5 business days of admitting the first resident. This notification may be done by phone, mail, email or fax.

An exit interview was conducted and a copy of this report was provided at the time of visit.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC809 (FAS) - (06/04)

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