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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701206
Report Date: 11/20/2023
Date Signed: 11/20/2023 01:37:40 PM


Document Has Been Signed on 11/20/2023 01:37 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
11/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Theresa PettapieceTIME COMPLETED:
02:00 PM
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On 11/20/23 at approximately 10:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management in relation to an incident report received. LPA Jensen met with Executive Director Theresa Pettapiece and explained the purpose of today's visit.

On 10/26/23 the Department received an incident report indicating that Resident 1 (R1) had an unwitnessed fall. Per facility protocol for unwitnessed falls, the resident was taken to the Emergency Department of the hospital and it was determined that she sustained a spinal fracture to L2.

LPA Jensen interviewed the Executive Director and R!. LPA Jensen reviewed records including the Plan of Operation, R1's physician report, charting notes, pre-placement appraisal and needs and service plan. LPA Jensen observed lunch service during the course of the visit.

During the annual inspection of 9/14/23, the facility was cited for a signal system in-operability and/or malfunctioning. The facility requested an extension for the plan correction through December 13, 2023. LPA Jensen discussed the facility's need to have an alternate plan for care and supervision so that resident needs can be met while the signal system is being upgraded. Technical assistance is being provided in the areas of signal systems, plan of operations and special diets.

No deficiencies are being cited as a result of this visit. An exit interview was conducted with Theresa Pettapiece and and a copy of this report and appeal rights were provided.


SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
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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