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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004526
Report Date: 08/26/2021
Date Signed: 08/26/2021 03:53:42 PM

Document Has Been Signed on 08/26/2021 03:53 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:FORDHAM AVENUE CARE HOMEFACILITY NUMBER:
507004526
ADMINISTRATOR:RABANG, CLARINAFACILITY TYPE:
735
ADDRESS:1406 FORDHAM AVENUETELEPHONE:
(209) 544-2781
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 3DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee Clarina RabangTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a Required Annual Inspection. LPA was met by staff and later by Licensee Clarina Rabang. LPA Lund explained the reason for the visit to Licensee Clarina Rabang.

LPA and Licensee toured the physical plant inside and outside to ensure all passageways, and other areas of potential hazard are free of obstruction. LPA observed the kitchen and dining area for the ability to prepare food. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility.

LPA observed the fire extinguisher(s), smoke detectors and pull alarm system. Facility has central heating and air.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations were observed during this visit. Exit interview held, copy of report given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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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