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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701206
Report Date: 08/28/2025
Date Signed: 08/28/2025 01:19:42 PM

Document Has Been Signed on 08/28/2025 01:19 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/
DIRECTOR:		RAJVIR SANDHUFACILITY TYPE:
740
ADDRESS:2325 ST. PAULS WAYTELEPHONE:
(530) 242-8300
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 73CENSUS: 41DATE:
08/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Rajvir Sandhu TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 08/28/2025, Regional Manager (RM), Stephenie Doub and Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. RM Doub and LPA Pascua were greeted by Facility Designated Administrator (FDA), Ravjir Sandhu and explained the purpose of the visit. The purpose of the visit was to conduct an annual visit.
Current census was 41. A brief interview with FDA Sandhu 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 16 residents. It was learned that there were a total of 11 residents on hospice.

LPA reviewed 5 resident files and 5 staff files. It was observed that 5 out 5 resident files did not have an updated Needs and Services Plan. It was observed that 1 out 5 staff did not have an First Aid/CPR on file. 1 out of 5 staff did have First Aid however CPR was not on file. 1 out 5 staff files did not have the mandated reporter statement signed and 1 out 5 staff files did not have their application on file. The Facility Designated Administrator has an active certificate #6069560740 and expires on 11/20/2026. LPA reviewed that fire drill log and is in compliance at this time.

A tour of the facility was conducted with FDA Sandhu.
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. 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GARDENS OF MODESTO, THE
FACILITY NUMBER: 502701206
VISIT DATE: 08/28/2025
NARRATIVE
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It was learned that resident bedrooms have been equipped with pull cords were observed.
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 Fire Master on 08/06/2025 and is in compliance at this time.
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. It was observed while comparing Electronic Medication Administration Record that the facility did not have an order for R1's medication on file. Further review shows that the facility did not have this medication on the EMAR since 01/15/2025. In addition, it was observed that the facility had medication poured into plastic containers for noon medication pass.
First aid kit was observed to be present and contained all of the required components at this time.
Perimeter fence and gates were observed. It was observed that the black gates next to the exit gate had a padlock attached which prohibited access to the back gate.
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
Licensees were offered and agreed to an opportunity to participate in Department's Technical support Program.
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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/28/2025 01:19 PM - It Cannot Be Edited


Created By: Arielle Pascua On 08/28/2025 at 12:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GARDENS OF MODESTO, THE
FACILITY NUMBER: 502701206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in by not ensuring the the exit gates were unlocked. LPA Pascua observed a padlock on the black gate which prohibited exit access. This poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Administrator took padlock off the black gate during visit. In addition, administrator states that a tour of the facility will tour of the facility every other day to ensure that the locks are not present. A statement of correction will be sent to LPA by POC date.
Type A
Section Cited
CCR
87465(a)(4)
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in not ensuring that R1's medication was not reflected on the Electronic Medication Administration Record. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Administrator states pharmacy will come and do an additional audit and well as in internal audit will be conducted.
Statement of correction willbe sent to LPA by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/28/2025 01:19 PM - It Cannot Be Edited


Created By: Arielle Pascua On 08/28/2025 at 12:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GARDENS OF MODESTO, THE
FACILITY NUMBER: 502701206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview, the licensee did not comply with the section cited above by not ensuring the medications were not transferred between containers. LPA observed that the medication for noon pass was pre-poured prior to administration, this poses a potential health,safety, and personal rights risks to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
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Administrator states that training will be conducted. A copy of this training will be provided to this LPA by POC.
Type B
Section Cited
CCR
87463(a)

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in by not ensuring that 5 out 5 residents had an updated reappraisals. This poses a potential health, safety, and personals rights risk to persons in care.
POC Due Date: 09/29/2025
Plan of Correction
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Administrator will resident file audit to ensure all reappraisals are done within a timely manner.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
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