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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002509
Report Date: 11/25/2024
Date Signed: 11/25/2024 04:09:36 PM

Document Has Been Signed on 11/25/2024 04:09 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, THEFACILITY NUMBER:
507002509
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, NICOLE EFACILITY TYPE:
740
ADDRESS:3529 FOREST GLENN DRTELEPHONE:
(209) 236-1900
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 107TOTAL ENROLLED CHILDREN: 0CENSUS: 86DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Nicole RodriguezTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 11/25/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Nicole Rodriguez and explained the purpose of the visit. The purpose of this visit was to conduct an annual visit.
Current census was 86. 65 current resident in assisted living and 21 residents in Memory Care. A brief interview with FDA Rodriguez was conducted.
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.

LPA reviewed 5 resident files and 5 staff files. All of which were complete and up to date.
The facility administrator has an active administrator certificate #7000291740 expires on 04/30/2025.
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.
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.
Lisa RiosTELEPHONE: (916) 969-9685
Arielle PascuaTELEPHONE: (916) 862-5907
DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 11/25/2024
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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 12/11/2023 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.


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

-LIC 308

-LIC 400

-LIC 500

-LIC 610e

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

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC809 (FAS) - (06/04)
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