502701206-9-14-2023-27-AS-APAA-CVNTFG-20230914144131

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701206
Report Date: 09/14/2023
Date Signed: 09/14/2023 02:42:15 PM

Document Has Been Signed on 09/14/2023 02:42 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: 36	DATE:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Theresa Pettapiece		TIME COMPLETED:	03:00 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 09/14/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA Pascua was greeted by staff member (SM), Maria Bargas and explained the purpose of the visit. LPA Pascua asked that SM Bargas inform the Facility Designated Administrator, Theresa Pettapiece that CCL was present at this time. LPA Pascua was informed that FDA Pettapiece was currently at a meeting and will be continuing the visit with Business Office Manager (BOM), Lindsay Beckett until she was able to come back to the facility. At 11:00am, LPA Pascua met with FDA Pettapiece and explained the purpose of the visit. Current Census was 36. A brief interview with FDA Pettapiece was conducted. This facility is licensed to served residents who are 60 and over with a capacity of 73. 73 of 73 residents may be deemed non-ambulatory. 10 of 73 may be bedridden. This facility also has a hospice waiver for 10 residents. It was learned that there were a total of 7 residents on hospice, 0 residents who are bedridden, and 3 residents receiving home health services at this time. LPA reviewed 7 resident files and 7 staff files. All resident and staff files were current and up to date. The Facility Designated Administrator has a expired Administrator certificate which expired 07/8/2023, however, has provided the department the proper documentation before the expiration date and is awaiting a renewal administrator certificate. LPA reviewed that fire drill log and is in compliance at this time. A tour of the facility was conducted. This facility has a main building in which has 4 separate wings, Napa, Central Valley, Yosemite and Carmel. Currently, there are no residents residing in Carmel due to the facility conducting renovations and is made inaccessible to the residents in care at this time. A separate building, Monterey was also observed and toured. LPA observed a small kitchenette that is equipped with microwave and an addition refrigerator present to cool, heat, and warm up food of the residents if necessary. All buildings were toured. LPA Pascua toured a bedroom from each wing and observed all furniture and furnishing to be in good repair and in compliance at this time. It was learned that resident bedrooms have been equipped with pull cords, however, are not in working condition 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: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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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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: 09/14/2023

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. It was learned that this facility has a signal system in resident bathrooms.
LPA Pascua observed a fire extinguisher in Monterey and all wings that were services by Jorgenson Co. on 10/03/2022 and is in compliance at this time.
Along with the Maintenance director, the LPA tested and observed that smoke detectors and carbon monoxide in rooms and in hallways to be in good repair.
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.
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 medication room was identified and tour. Medication carts for all four wings 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.
A tour of the laundry rooms were conducted. The facility has a total of 3 washers and 3 dryers at this time. It was observed during this tour that the main laundry room had two large holes in the wall, water damage on the baseboards and water spouts and flooring throughout the laundry room was lifted.
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.
The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/14/2023 02:42 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in by not ensuring the the laundry room and pull cords in the bedrooms were in good repair. LPA observed two large holes, water damage under the water spouts, and baseboards, and floorings throughout the laundry room was lifting off. LPA learned through interview that the pull cords in each resident bedrooms have not been in working condition. This poses an potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	The administrator stated that a plan to repair the laundry room and pull cord system will be conducted and be provided to the LPA by the POC date. In addition, the administrator shall provide receipts and proof of service to the LPA by the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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