502701277-7-3-2026-27-AS-NWPN-DVDQYZ-20260625123557

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701277
Report Date: 06/25/2026
Date Signed: 07/03/2026 02:24:11 PM

Document Has Been Signed on 07/03/2026 02:24 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:	RIVERETTE RESIDENCE		FACILITY NUMBER:	502701277
ADMINISTRATOR/ DIRECTOR:	MELINA MENDIOLA		FACILITY TYPE:	735
ADDRESS:	1409 RIVERETTE DRIVE		TELEPHONE:	(209) 416-4317
CITY:	MODESTO	STATE: CA	ZIP CODE:	95351
CAPACITY: 4		CENSUS: 4	DATE:	06/25/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Melina Mediola		TIME VISIT/ INSPECTION COMPLETED:	12:45 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	Licensing Program Analyst, LPA, Noel Wolf Petersen arrived to the facility to conduct an annual inspection, LPA met with administrator Melina Mediola to explain the purpose of the visit. Physical inspection was completed, The physical inspection included but was not limited to the kitchen, common areas, bedrooms, bathrooms, exteriors, and evacuation route gates. First aid kit has required items, fire extinquishers are dated may 1, 2025. LPA asked the fire extinguishers to get replaced/recharged before the inspection was completed. The administrator opted to replace. kitchen has adequate lockable storage for sharps/toxics/medications. 2 medications were checked against mars, one clients mar did not reflect a results section being filled out in at least 3 instances. LPA gave guidance for the administrator to document refusals using the same process as for PRN's minus the results category, and PRN results section to be filled out with a fifteen minute check on its effectiveness/not/hazzardous. Kitchen has adequate supply of food for 2 days perishable and 7 days nonperishable foods. CommonExterior + evacuation route gate: common areas are out of repair there are some holes in the facility, one into the hall (roughly computer printer paper sized), one thats in the living room space (roughly softball sized). The common areas have enough room for activites, exterior has some rusted tools/barbells and unsecured toxics(paint cans). There is a lockable shed to store these materials. One exterior opening gates to the alley swings freely and latches closed. The other gate drags into the ground and does not latch into anything. Bedroomsbathrooms: the bedrooms have required furniture and furnishings. The bathrooms have the delivered water temperature measured at the sink between 105-120*F. bathroom hardware is in good repair. Continued on c page.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026

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: RIVERETTE RESIDENCE	FACILITY NUMBER: 502701277
	VISIT DATE: 06/25/2026

NARRATIVE

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Client records were reviewed, for 4 clients. One client is missing their admission agreement. LPA was provided by the administrator that it was removed for some purpose related to an update due to a recent group of behaviors and updates from family. IPP will probably have some recent changes. LPA is expecting a update to the clients services to reflect his current needs. 3 of 4 client files had admission agreements and up to date IPPs that reflect the needs of the clients. 4 of 4 have tb health screenings and recent medical assessments.

Staff records were reviewed, for 5 staff. 2 of 5 staff records are missing thier backround clearance paperwork in the staff file. one of those two have a Gaurdian eligibility currently, the other is In process. LPA gave guidance not to have the staff work while they don't have backround clearance paperwork in thier staff file.

Administrator docs were reviewed: LIC 500, Lic 9020, required postings(ombudsman, personal rights, federal workers rights, facility sketch, menus, and activies callender), fire drill log, facility emergency plan, infection control plan, workers comp insurance, administrator certificate, facility license. files are present and up to date, the adminstrator HIV training is going to be sent to the lpa noel.wolfpetersen@dss.ca.gov.

2 clients were interviewed. 1 staff was interviewed.

2 citations issued, copy of the report was read and given to the administrator, appeal rights provided, exit interview conducted. LPA has a hardware issue, and will provide the files from the visit electronicly to the email on file, and they will be printed.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/03/2026 02:24 PM - It Cannot Be Edited

Created By: Noel Wolf Petersen On 06/25/2026 at 11:49 AM

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: RIVERETTE RESIDENCE	FACILITY NUMBER: 502701277
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1522(c)(1)

General Provisions

(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility.  This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 5 staff records which did not have backround clearance, gaurdian shows the record in process, administraor has not yet updated the LIC 500, but gave the statement the particular staff has provided care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/26/2026
	Plan of Correction
1 2 3 4	LPA asked the Administrator to remove the staff from the schedule and submit a updated LIC 500 by the POC date. until the backround clearance comes through, admin should call CPMB and investigate if there is a hold up of some kind.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

	Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/03/2026 02:24 PM - It Cannot Be Edited

Created By: Noel Wolf Petersen On 06/25/2026 at 11:49 AM

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: RIVERETTE RESIDENCE	FACILITY NUMBER: 502701277
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Observation and interview, the licensee did not comply with the section cited above in 6 instances of concern(2 holes in the walls(1 softball sized by the outlet under the kitchen interior window, 1 computer paper size in the middle of the western wall on the north side of the property), 2 paint cans left accessible to the clients, 1 rusted tree trimming tool left accessible to clients, 1 rusted barbell left accessable to clients) whichposed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/23/2026
	Plan of Correction
1 2 3 4	LPA asked for the work orders to proceed to completion and the items to be removed/stored in a way that removes the safety concern. Administrator should send pictures to the LPA, noel.wolfpetersen@dss.ca.gov by the poc date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

	Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026

LIC809 (FAS) - (06/04)

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