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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502701132
Report Date:
04/10/2023
Date Signed:
06/09/2023 01:34:53 PM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
06/09/2023 01:34 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC
,
2525 NATOMAS PARK DR. STE.270
SACRAMENTO
,
CA
95833
FACILITY NAME:
GRACEFUL LIVING AT VILLAGE ONE
FACILITY NUMBER:
502701132
ADMINISTRATOR:
SUASIN, LETECIA
FACILITY TYPE:
740
ADDRESS:
3128 AMOS CT
TELEPHONE:
(209) 595-1028
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95356
CAPACITY:
6
CENSUS:
6
DATE:
04/10/2023
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
02:00 PM
MET WITH:
Rainilda Clavano
TIME COMPLETED:
03:30 PM
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Unannounced Annual Continuation visit conducted today by Licensing Program Analysts (LPAs) Kimberly Viarella and Charlie Yang. LPAs were met by staff member Rainilda Clavano. Delivered Annual that was conducted on 03/27/23.
SUPERVISOR'S NAME:
Liza King
TELEPHONE:
(916) 263-4700
LICENSING EVALUATOR NAME:
Kimberly Viarella
TELEPHONE:
916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
04/10/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/10/2023
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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