507001908-3-24-2023-27-AS-APAA-CQ8LP2-20230324085512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507001908
Report Date: 03/22/2023
Date Signed: 03/24/2023 08:55:47 AM

Document Has Been Signed on 03/24/2023 08:55 AM - 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 HOME		FACILITY NUMBER:	507001908
ADMINISTRATOR:	GUILLERMINA ZEPEDA		FACILITY TYPE:	740
ADDRESS:	1344 E. ORANGEBURG AVENUE		TELEPHONE:	(209) 571-0116
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	31	CENSUS: 30	DATE:	03/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	GUILLERMINA ZEPEDA		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/22/2023 at 1:00pm, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct an Annual Visit. LPA Pascua was greeted by Facility Designated Administrator (FDA) Guillermina Zepeda and explained the purpose of the visit. Current census was 30. A brief interview was conducted with FDA Zepeda. This facility is licensed for 31 residents, of which 25 may be non-ambulatory. LPA reviewed 6 resident files. 6 out of 6 resident files were current and up to date. LPA reviewed 6 staff files. 6 out of 6 staff files were current and up to date. The facility Administrator has an administrator certificate #6025364740 and is awaiting renewal from the department. LPA Pascua observed a locked centralized stored medication cabinet located in the office. Along with the staff member, the LPA observed, reviewed, and compared resident medication and electronic medication dispensing logs. First Aid Kit was present and contained all of the required components. A tour with FDA Zepeda was conducted. Fire extinguisher located throughout the facility. was serviced by U.S.A. Stanislaus Fire on 06/16/2022. 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 furniture and furnishings were sufficient and able to meet the needs of the residents at this time. 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.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MODESTO GUEST HOME	FACILITY NUMBER: 507001908
	VISIT DATE: 03/22/2023

NARRATIVE

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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.
The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/24/2023 08:55 AM - 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: 03/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

(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 requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section above in 87303(a). LPA observed parts of debris and items in the back of the facillity property. This which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/22/2023
	Plan of Correction
1 2 3 4	Administrator agreed to clean up debris and excess items in the back of the facility and provide the LPA a picture to the LPAs email by the POC date 04/22/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC809 (FAS) - (06/04)

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