<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502701290
Report Date:
09/26/2024
Date Signed:
09/26/2024 12:41:54 PM
Document Has Been Signed on
09/26/2024 12:41 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:
CARVER CARE RESIDENTIAL
FACILITY NUMBER:
502701290
ADMINISTRATOR/
DIRECTOR:
ASHLEY M GUDINO
FACILITY TYPE:
735
ADDRESS:
1009 CARVER ROAD
TELEPHONE:
(209) 204-5157
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95350
CAPACITY:
70
CENSUS:
54
DATE:
09/26/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:
Administrator Ashley Gudino
TIME VISIT/
INSPECTION COMPLETED:
01:00 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) Jason Lund arrived unannounced to conduct a case management visit. LPA Lund met with Administrator Ashley Gudino and explained the reason for the visit. Census: 54
LPA Lund received Unusual/Incident Report dated 9/25/2024. On 9/24/2024 Client (C1) was using his portable oxygen and trying to smoke a cigarette and caught fire. C1 was sent to the ER and came back the same day. C1 is not to use the portable oxygen for outings only.
No deficiencies were observed and cited during this visit.
Exit interview conducted and report left.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Jason Lund
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/26/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1