<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701309
Report Date: 09/09/2024
Date Signed: 09/10/2024 10:42:54 AM

Document Has Been Signed on 09/10/2024 10:42 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:ASIANA RESIDENTIAL SERVICES #2FACILITY NUMBER:
502701309
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, GEORGINAFACILITY TYPE:
735
ADDRESS:1317 MORADA DRIVETELEPHONE:
(209) 635-1885
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 4CENSUS: 3DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH: Administrator Sajida Khan TIME VISIT/
INSPECTION COMPLETED:
03:15 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 required/annual inspection. LPA Lund met with Administrator Sajida Khan and explained the reason for the visit. Census: 3

LPA Lund and Administrator Sajida Khan toured/inspected the physical plant inside and outside to ensure there are no safety hazards to residents. 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 114 *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),(8/16/2024) , 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. LPA Lund reviewed two clients’ files and three staff files and are in compliance.

No deficiencies were observed during this visit. Exit interview held, copy of report given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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