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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001908
Report Date: 04/26/2024
Date Signed: 04/26/2024 03:04:55 PM


Document Has Been Signed on 04/26/2024 03:04 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: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: 26DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Guillermina Zepeda TIME COMPLETED:
01:00 PM
NARRATIVE
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On 04/26/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Guillermina Zepeda and explained the purpose of the visit.
Current census was 26. A brief interview with FDA Zepeda was conducted.
This facility is licensed for 31 residents, of which 25 may be non-ambulatory.

A tour with FDA Zepeda was conducted. Fire extinguisher located throughout the facility. was serviced by U.S.A. Stanislaus Fire on 06/29/2023 and is in compliance at this time. Carbon monoxide, smoke detectors and call lights were observed to be in good repair.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that there only one couch available able to sit 2-3 residents at a time and 4 plastic chairs around the common area.
Kitchen area was toured. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply to meet the residents needs. Knives were observed to be locked and made inaccessible to the residents in care. Additional food supply was identified in an outside storage.
A tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies were made inaccessible to the residents at this time.
A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. It was observed that the resident bathrooms had cracked tiles near the drainage area, and had baseboards around the shower area to have been lifting. It was advised at this time the facility does not use this bathroom until this has been repaired.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.
A tour of the second building was conducted. Dining areas, living areas, and all other areas intended for resident use were toured in this building. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
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SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MODESTO GUEST HOME
FACILITY NUMBER: 507001908
VISIT DATE: 04/26/2024
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The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.
Due to insufficient time to conduct records review, the LPA will return at a later date to continue the annual visit.

A technical advisory was provided for 87555(26)(b).

Per California Code of Regulations, Title 22 Division 6, Chapter 8, one deficiency is being cited today in violation of California Code of Regulations.

An exit interview was conducted, a copy of this report and appeals rights were provided to the Administrator at the end of this visit.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/26/2024 03:04 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MODESTO GUEST HOME
FACILITY NUMBER: 507001908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2024
Section Cited
CCR
87307(d)(1)

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(1) Sufficient room shall be available to accommodate persons served in comfort and safety.
This is not met as evidenced by:
Based on observation the Licensee did not ensure that the facility had a sufficient amount of space and furnishings to ensure
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Licensee shall provide a statement of correction and acknowledgement to the LPA by the POC date. Licensee shall also provide additional sitting areas for the residents and provide a picture to the LPA by the POC date.
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that resident's are able to sit in common areas. LPA observed one couch only only able to sit 2-3 residents and 4 plastic chairs around the tv room.
This poses an potential health, safety, and personal rights risks to persons in care.
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Type B
04/26/2024
Section Cited
CCR87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This is not met as evidenced by:
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Licensee shall provide a plan in place to fix and maintain bathrooms by POC date. Any purchases or services rendered must be relied to the LPA by the POC date.
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Based on observation and interview, the Licensee did not ensure that the facility bathroom has been in good repair. LPA observed a large crack in the resident restroom used in the front building along with the baseboards peeling away from the wall. This poses a potential health, safety and personal rights risks to persons in care.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
LIC809 (FAS) - (06/04)
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