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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003595
Report Date: 07/08/2021
Date Signed: 07/08/2021 01:46:48 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:GRACEFUL LIVING AT MODESTOFACILITY NUMBER:
507003595
ADMINISTRATOR:MATIS, VOICA V.FACILITY TYPE:
740
ADDRESS:3709 CORRINE LANETELEPHONE:
(209) 545-1352
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 5DATE:
07/08/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Linda Aguilar Direct Care StaffTIME COMPLETED:
01:45 PM
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Licensing Program Analyst's Sarah Hurt and Ruth Wallace conducted an unannounced plan of correction (POC) visit. LPA's met with Linda Aguilar and explained the purpose of the visit. LPA's re tested water temperature and was 110F which meets the requirements of our regulations.

Deficiency was cleared today July 8, 2021 and POC letter was given to facility.

Exit interview was conducted with staff and a copy of this report was left at facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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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