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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701450
Report Date: 11/18/2024
Date Signed: 11/19/2024 05:04:53 PM

Document Has Been Signed on 11/19/2024 05:04 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/
DIRECTOR:
ISSAKHANI, STEPHANYFACILITY TYPE:
740
ADDRESS:1745 ELDENA WAYTELEPHONE:
(925) 594-1122
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 160CENSUS: 54DATE:
11/18/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Licensee Rani Dhillon TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct post-licensing visit. LPA Lund met with Licensee Rani Dhillon explained the purpose of the visit. Census: 54

LPA Lund & Licensee Rani Dhillon 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 108.7 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 5 resident and 3 staff files, including criminal record clearances. First aid kit was checked and is complete.

No deficiencies were observed and cited during this visit. Exit interview held and a copy of report given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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