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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001908
Report Date: 12/22/2021
Date Signed: 12/23/2021 08:41:24 AM

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:MODESTO GUEST HOMEFACILITY NUMBER:
507001908
ADMINISTRATOR:GUILLERMINA ZEPEDAFACILITY TYPE:
740
ADDRESS:1344 E. ORANGEBURG AVENUETELEPHONE:
(209) 571-0116
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:31CENSUS: 30DATE:
12/22/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Guillermina Zepeda, Administrator (AD)TIME COMPLETED:
02:32 PM
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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced POC visit to the facility to verify correction of citations issued during the Infection Control/ Annual visit on 12/08/2021.

LPA reviewed documents required per the POC. LPA toured and observed physical plant corrections were made.

Deficiencies cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC by POC due date.

Facility was provided POC cleared letter.

Exit interview conducted and a copy of this report was provided to Guillermina Zepeda, Administrator (AD) .
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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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