507002509-11-15-2023-27-AS-APAA-CXM5EV-20231115185408

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507002509
Report Date: 11/15/2023
Date Signed: 11/15/2023 06:54:37 PM

Document Has Been Signed on 11/15/2023 06:54 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:	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: 83	DATE:	11/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Nicole Rodriguez		TIME COMPLETED:	04:00 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 11/15/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Business Office Director (BOD), Anna Jones and explained the purpose of the visit. LPA asked that BOD Jones call the Facility Designated Administrator, Nicole Rodriguez and inform her that CCL was present at this time. Shortly after, LPA met with FDA Rodriguez and explained the purpose of the visit. The current census to this facility was 83. 69 resident reside in assisted living and 14 residents in Memory Care. This facility is licensed to served 60 elderly residents,of which, all my be non-ambulatory. This facility has a fire clearance for delayed egress and has a hospice waiver for 10. A tour of the facility was conducted with BOD, Jones. All rooms designated as activity areas and common areas for resident use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the residents at this time. Office rooms and other areas intended for resident use were toured. Kitchen area was toured. Facility freezer and refrigerator units were toured. LPA reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. Knives were observed to be locked and made inaccessible to the residents at this time. It was observed in that the facility has cafe areas equipped with a microwave and addition refrigerator present to cool, heat, and warm up food of the residents if necessary. Storage area for chemicals and cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Additional incontinent supplies were also identified. A tour of the facility resident bedrooms was conducted. Furniture and furnishings were observed to sufficient and able to meet the needs of the residents at this time. A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STRATFORD AT BEYER PARK, THE	FACILITY NUMBER: 507002509
	VISIT DATE: 11/15/2023

NARRATIVE

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Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Additional incontinent supplies were also identified.
Medication cabinet was reviewed. It was learned that narcotics and all other medications were housed in medication carts that were used to store and dispense medications to the residents at this time. This facility has an electronic Medication Administration Record system. A brief interview was conducted with facility staff responsible for handling, dispensing, and documentation of the medications at this time. First aid kit was observed to be present and contained all of the required components at this time. First aid kit was observed to be present and contained all of the required components at this time.
A tour of the facility memory care unit was conducted.
Exterior grounds of this facility was toured. Perimeter fence and gates were observed to be functional and in good repair at this time. Delayed egress and other safety measures were observed to be functional at this time.
Fire extinguishers, located and placed throughout the facility, were observed to have been annually inspected on 12/07/2022 by the local fire extinguisher company noted as Assured and in compliance at this time. All smoke and carbon monoxide detectors were present and working at this time.
LPA Pascua reviewed 8 resident files and 5 staff files. 8 out 8 resident files were current and up to date. 5 out 5 staff files were current and up to date.

The following forms and documents were requested to be updated and submitted into CCL:

-LIC 308

-LIC 400

-LIC 500

-LIC 610

Technical assistance is being provided today for 87465(h)(5)

As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to Facility Designated Administrator, Nicole Rodriguez.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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