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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701206
Report Date: 10/17/2023
Date Signed: 10/17/2023 02:30:52 PM


Document Has Been Signed on 10/17/2023 02:30 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, THEFACILITY NUMBER:
502701206
ADMINISTRATOR:PETTAPIECE, THERESAFACILITY TYPE:
740
ADDRESS:2325 ST. PAULS WAYTELEPHONE:
(530) 242-8300
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:73CENSUS: 31DATE:
10/17/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Theresa PettapieceTIME COMPLETED:
01:00 PM
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On 10/17/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a Plan of Correction Visit. LPA Pascua was greeted by Facility Designated Administrator, Theresa Pettapiece and explained the purpose of this visit. The purpose of this visit was to review the deficiencies cited on a prior annual visit on 09/14/2023.

Current census was 31 residents. A tour of the facility was conducted.

LPA toured the facility and reviewed the deficiencies to make sure that they had been corrected and brought into compliance at this time.

Deficiency cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC by POC due date.

Facility was provided POC cleared letter.

There were no deficiencies observed or cited during this visit. An exit interview was conducted, a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
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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