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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701309
Report Date: 08/31/2023
Date Signed: 08/31/2023 12:19:25 PM

Document Has Been Signed on 08/31/2023 12:19 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:ASIANA RESIDENTIAL SERVICES #2FACILITY NUMBER:
502701309
ADMINISTRATOR:HERNANDEZ, GEORGINAFACILITY TYPE:
735
ADDRESS:1317 MORADA DRIVETELEPHONE:
(209) 635-1885
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 4CENSUS: 0DATE:
08/31/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sajida KhanTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived announced to conduct a Pre-Licensing Inspection. LPA Lund met with Sajida Khan and explained the reason for the visit.

LPA Lund and Sajida Khan toured/inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed there are no residents at this time. LPA observed the kitchen area, dining area, bedrooms, restrooms, storage areas, and laundry rooms. LPA observed required furniture, and lighting throughout the facility. The hot water temperature was measured at 115 *F which is within the required range of 105-120*F. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed centrally stored medications area locked and inaccessible to future residents. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the home. Facility has central heating and air. Staff and Resident files will be readily available for review and kept in the office locked in a cabinet.

Component III conducted. Licensure pending. The facility is still waiting for approval from Valley Mountain Regional Center (VMRC)

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations were observed during this visit. Exit interview held, copy of report given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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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