502701246-9-27-2023-27-AS-APAA-CW42KD-20230927172743

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701246
Report Date: 09/27/2023
Date Signed: 09/27/2023 05:27:59 PM

Document Has Been Signed on 09/27/2023 05:27 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:	DIGNITY POINT SENIOR HOME CARE, L.L.C.		FACILITY NUMBER:	502701246
ADMINISTRATOR:	MOLINA, ROMMEL		FACILITY TYPE:	740
ADDRESS:	3708 BOLD RULER CT		TELEPHONE:	(408) 824-0488
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS: 6	DATE:	09/27/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Rommel Molina		TIME COMPLETED:	03:30 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 09/27/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a post-licensing visit. LPA was greeted by staff member, Mohini Kanter and explained the purpose of the visit. LPA asked that SM Kanter call the Facility Designated Administrator (FDA) to inform them that CCL was present at this time. Shortly after, LPA met with FDA Rommel Molina and explained the purpose of the visit. This facility is licensed to served 6 non-ambulatory residests of which 1 may be bedridden. This facility also holds a hospice waiver for 6 and has a dementia plan on file. Current census was 6. A brief interview with FDA Molina was conducted. LPA reviewed 3 resident files and 2 staff files. It was learned that there are 3 residents receiving hospice services at this time. The Facility Designated Administrator, Rommel Molina, hold a current and active administrator certificate #606263740 and is valid until 09/28/2023. Tour of the facility was conducted. Carbon monoxide and smoke alarms were present and were in working condition. Common areas for resident use were toured. Furniture and furnishings were observed to be present and in compliance. A tour of the bathrooms was conducted. Hot water temperatures were taken to ensure that the hot water being dispensed was within the allowed range of 105-120 degrees at this time. Grab bars were present and functional. Resident bedrooms were toured. Furniture and furnishing were observed to be present and in good condition. A linen closet was located in the hallway. LPA observed a sufficient amount of linens at this time. The kitchen area was toured. Facility freezer and refrigerator showed to be functional and in compliance at this time. A tour of the pantry was conducted. LPA observed that there was a 7-day nonperishable food supply 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: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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: DIGNITY POINT SENIOR HOME CARE, L.L.C.	FACILITY NUMBER: 502701246
	VISIT DATE: 09/27/2023

NARRATIVE

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The fire extinguisher, located in the kitchen area, was serviced by Jorgenson Co on 05/04/2023 and is in compliance at this time.

Garage area was toured. LPA observed refrigerator unit which will store additional food supplies.
This facility has a centralized medication cabinet that was observed to be locked and made inaccessible to the residents.

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.

No deficiencies were observed or cited during this visit. 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: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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