507002509-11-5-2021-27-AS-ADGA-C8GRPX-20211105131240

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507002509
Report Date: 11/05/2021
Date Signed: 11/05/2021 01:12:47 PM

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:	STRATFORD AT BEYER PARK, THE		FACILITY NUMBER:	507002509
ADMINISTRATOR:	RODRIGUEZ, NICOLE E		FACILITY TYPE:	740
ADDRESS:	3529 FOREST GLENN DR		TELEPHONE:	(209) 236-1900
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	107	CENSUS: 67	DATE:	11/05/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Nicole Rodriguez, Administrator (AD)		TIME COMPLETED:	02:07 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	Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA was greeted by Erika Yepez, Concierge (S1) and met with Nicole Rodriguez, Administrator (AD). Census: 67 total (52 in Assisted Living, 15 in Memory Care). LPA and AD, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas. Entrance is locked and upon entering facility, temperature check and covid symptom screening was conducted. Offices located to left of entrance, visitor area, library, family room, and private dining room located to right of building. Kitchen located in the center of the building. Assisted living located past the offices. Memory Care is located at the back of the building. Facility hallways are clear and free from debris. Rugs and floors are maintained. Elevator permit good until 10/21. Facility provided proof of provisional extension dated 10/26/21. LPA observed housekeeping cart in hallway locked. Maintenance manager on site, Bill Cates (S2). LPA observed dining area and residents having lunch. LPA observed activities calendar posted and current. LPA observed residents engaged in activities. LPA observed Beauty Shop open and proper safety practices implemented. LPA observed movie room. 809 CONT. >>>>>>>>>>>>>>>>>>>>>>>>>>>

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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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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: STRATFORD AT BEYER PARK, THE	FACILITY NUMBER: 507002509
	VISIT DATE: 11/05/2021

NARRATIVE

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LPA observed resident in Memory Care participating in activities. LPA observed residents in Memory Care in living room engaged with caregiver.

64 staff of which 62 vaccinated, the remaining 2 unvaccinated due to personal reasons.
67 residents of which 66 are vaccinated. LPA reviewed 10 staff files, all are complete. LPA reviewed 5 resident files in Assisted Living and 5 resident files in Memory Care. All files complete.

LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 105 degrees in residents bathroom with the AD which is in required range of 105 to 120 degrees.

Last Fire/Disaster Drill conducted on 9/21/2021. ANSUL system dated 7/9/21. Kitchen extinguisher dated 12/14/20. Fire extinguishers throughout facility dated 10/12/21.
LPA and AD observed centrally stored medications in both Assisted Living and Memory Care Med rooms. LPA observed facility utilizing EMAR system and confirmed the facility has a backup system. LPA observed LIC 622 complete and confirmed proper intake, disposal practices are conducted. LPA observed all medications locked.

Administrator Certificate valid until 4/30/2023.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, NO deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report provided.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC809 (FAS) - (06/04)

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