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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701450
Report Date: 08/26/2024
Date Signed: 08/26/2024 07:30:59 PM


Document Has Been Signed on 08/26/2024 07:30 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:CASA DE MODESTOFACILITY NUMBER:
502701450
ADMINISTRATOR:ISSAKHANI, STEPHANYFACILITY TYPE:
740
ADDRESS:1745 ELDENA WAYTELEPHONE:
(925) 594-1122
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:160CENSUS: 48DATE:
08/26/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Stephany Issakhani TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an pre-licensing visit. LPA Lund met with Administrator Stephany Issakhani explained the purpose of the visit. Census:48

LPA Lund & Administrator Stephany Issakhani toured/inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, medication room, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in the facility. LPA observed sufficient seven- day non-perishable and two- day perishable food supplies. Hot water temperature was measured at 108.3 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers (2/12/2024) and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed 4 resident and 4 staff files, including criminal record clearances. All staff are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete. Fire drill completed 4/2024.

Comp 111 was completed for Administrator Stephany Issakhani.

No deficiencies were observed and cited during this visit. Exit interview held and a copy of report given.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
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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