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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001908
Report Date: 03/11/2022
Date Signed: 03/11/2022 03:44:16 PM


Document Has Been Signed on 03/11/2022 03:44 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: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: 28DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:GUILLERMINA ZEPEDA - ADMINISTRATORTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Annual / Infection Control Inspection visit on this date. LPA met with Guillermina Zepeda, Administrator (AD). Administrator Certificate expires March 21, 2023.

LPA and AD, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas.

LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 115.2 F degrees in residents bathroom with the AD which is in required range of 105 to 120 degrees. Fire extinguishers expires May 24, 2022. Fire alarm and carbon monoxide functional. LPA observed centrally stored medications locked. LPA observed toxins stored in locked cabinet.
LPA reviewed four staff and four resident files. Resident emergency contact complete. LPA observed all staff files complete. All staff completed CPR class on 10/9/2021. All persons in facility fully vaccinated with exception of 2 residents due to personal reasons. LPA observed resident practicing social distancing.
LPA observed 30 days of PPE supplies. LPA observed the required postings displayed.
LPA observed sharps stored in kitchen and kitchen door locked.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, one deficiency is being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report and appeal rights given to AD.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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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Document Has Been Signed on 03/11/2022 03:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 507001908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in six gallons of bleach were stored in locked food pantry which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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Administrator removed the six gallons of bleach immediately from food pantry area. LPA observed Administrator lock up bleach in separate storage area for soaps, detergents, cleaning compounds or similar substances. No further action required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2