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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502701290
Report Date:
10/21/2024
Date Signed:
10/21/2024 01:07:13 PM
Document Has Been Signed on
10/21/2024 01:07 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:
53
DATE:
10/21/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:
Staff Le Ann Blocker
TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to do a case management visit. LPA Lund met with Staff Le Ann Blocker and explained the reason for the visit. Census: 41
LPA Jason Lund received an Unusual Incident/Injury Report (LIC 624) on 10/10/2024 from the facility stating that two client’s eloped (AWOLS) from the facility on 10/8/2024 and 10/9/2024. Client (C1’s) LIC 602 dated 7/31/2024 states that C1 can leave the facility unassisted. Client (C2) LIC 602 dated 1/26/2024 dated 1/26/2024 can leave the facility unassisted.
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:
10/21/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/21/2024
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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