502701206-9-21-2022-27-AS-APAA-CJH26C-20220921170652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701206
Report Date: 09/21/2022
Date Signed: 09/21/2022 05:07:01 PM

Document Has Been Signed on 09/21/2022 05:07 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:	GARDENS OF MODESTO, THE		FACILITY NUMBER:	502701206
ADMINISTRATOR:	PETTAPIECE, THERESA		FACILITY TYPE:	740
ADDRESS:	2325 ST. PAULS WAY		TELEPHONE:	(530) 242-8300
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	73	CENSUS: 28	DATE:	09/21/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Theresa Pettapiece		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/21/2022 at 10:30am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a pre-licensing visit. LPA Pascua met with Administrator, Theresa Pettapiece and explained the purpose of this visit. The purpose of this visit is to conduct a pre-licensing visit due to a change of ownership. This facility will have a dementia program on file. A brief interview was conducted with Administrator, Pettapiece. Administrator certificate is current and is valid until 07/07/2023. Current census was 28. At 10:35am, LPA Pascua iniatied a tour of the facility with Administrator, Pettapiece. All fire extinguishers placed throughout the facility were observed to have been annually inspected by the local fire extinguisher company, Jorgensen Company and is valid until 10/05/2022. It was observed that the facility is still conducting room renovations in two corridors of this facility and are closed off to make it inaccessible to the residents in care at this time. The facility has a central screening point and have a 30-day supply of PPE. Entrances and exits used were observed to be supplied with hand sanitizer and masks at this time. All rooms designated as activity areas and common areas for resident use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the residents at this time. Office rooms and other areas intended for resident use were toured. Kitchen area was toured. Facility freezer and refrigerator units were toured. LPA reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. It was observed in each corridor that there was a microwave and addition refrigerator present to cool, heat, and warm up food of the residents if necessary. Storage area for chemicals and cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Additional incontinent supplies were also identified. A tour of the facility resident bedrooms was conducted. Furniture and furnishings were observed to sufficient and able to meet the needs of the residents at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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: GARDENS OF MODESTO, THE	FACILITY NUMBER: 502701206
	VISIT DATE: 09/21/2022

NARRATIVE

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A review of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees
A medication room was identified and tour. Medication cart was reviewed and the policies for dispensing, storing, and documentation was discussed with facility staff responsible for the medication management at this time.
First aid kit was observed to be present and contained all of the required components at this time.
Exterior grounds of this facility was toured. Perimeter fence and gates were observed to be functional and in good repair at this time. Delayed egress and other safety measures were observed to be functional at this time.

This facility has been observed to be in compliance at this time. Component III was reviewed with Administrator, Pettapiece.

There were no deficiencies observed during the course of this Prelicensing visit.

Exit Interview was conducted and a copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC809 (FAS) - (06/04)

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