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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701246
Report Date: 06/11/2024
Date Signed: 06/13/2024 08:21:48 AM


Document Has Been Signed on 06/13/2024 08:21 AM - 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:DIGNITY POINT SENIOR HOME CARE, L.L.C.FACILITY NUMBER:
502701246
ADMINISTRATOR:MOLINA, ROMMELFACILITY TYPE:
740
ADDRESS:3708 BOLD RULER CTTELEPHONE:
(408) 824-0488
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 3DATE:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Rommel MolinaTIME COMPLETED:
02:30 PM
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On 06/11/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by staff member (SM), Suzanne Lloren and explained the purpose of the visit. LPA asked SM Lloren to call the Facility Designated Administrator (FDA), Rommel Molina and inform him that CCL was present at this time. Shortly after, LPA met with FDA Molina and explained the purpose of the visit.

This facility is licensed to serve residents 60 and older, of which all 5 may be non-ambulatory and 1 may be bedridden in bedroom 4. This facility also holds a hospice waiver for 6 and has a dementia plan on file.
Current census was 3. A brief interview with FDA Molina was conducted.
LPA reviewed 3 resident files. 3 resident files were complete and up to date. LPA reviewed 2 staff files. 2 staff files were current and up to date.
The Facility Designated Administrator, Rommel Molina, hold a current and administrator certificate #606263740 and is awaiting renewal from the department.
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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DIGNITY POINT SENIOR HOME CARE, L.L.C.
FACILITY NUMBER: 502701246
VISIT DATE: 06/11/2024
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The fire extinguisher, located in the kitchen area, was serviced by Jorgenson Co on 05/08/2024 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC809 (FAS) - (06/04)
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