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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701153
Report Date: 05/09/2023
Date Signed: 05/09/2023 01:29:57 PM


Document Has Been Signed on 05/09/2023 01:29 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ETERNITY CARE HOME 2FACILITY NUMBER:
502701153
ADMINISTRATOR:PAYLA, MARIA ALONAFACILITY TYPE:
740
ADDRESS:518 WEST GRANGER AVENUETELEPHONE:
(209) 204-9794
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:5CENSUS: 4DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Maria Payla TIME COMPLETED:
01:30 PM
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Licensee Program Analyst Jason Lund arrived unannounced to conduct an annual/required visit. LPA Lund met with Licensee/Administrator Maria Payla and explained the reason for the visit. Census 4

LPA Lund and Administrator Maria Payla toured/inspected the facility including common areas, resident bathrooms, kitchen, dining room, laundry, storage, and outside yard area. The facility is clean and in good repair and no odors were detected in areas toured. No hazards were noted in courtyard areas, hallways, doorways, etc. No equipment was stored in public areas. Fixtures and furniture all appear to be in good condition. Cleaning solutions are stored separately from food. Handrails are present in all shower and toilet areas, are secured. Room temperature was comfortable in facility. There are no bodies of water on the premises. A fire clearance was granted for 5 non-ambulatory clients.

The facility has a supply of bedding and towels. First aid supplies are available in several locations. Laundry equipment present, working telephone, emergency lighting. The Facility medication cabinet is in the kitchen and secure. The facility has 7-day nonperishable and 2-day nonperishable on hand. Cooler/freezer appear to be at appropriate temperatures.

LPA Lund reviewed two staff and two residents files.

No Deficiencies citied during the visit.
Exit interview conducted with Administrator Maria Payla and report left.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023
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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