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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005425
Report Date: 07/20/2022
Date Signed: 07/20/2022 11:52:32 AM


Document Has Been Signed on 07/20/2022 11:52 AM - 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:PINE MANOR CARE HOMEFACILITY NUMBER:
507005425
ADMINISTRATOR:KHAN, SAJIDAFACILITY TYPE:
740
ADDRESS:1601 SHELDON DRIVETELEPHONE:
(209) 524-2878
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:6CENSUS: 0DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Sajida KhanTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the above address unannounced to conduct a annual/required inspection. LPA Lund explained the reason for the visit to Administrator Sajida Khan. Census 0

LPA Lund and Administrator Sajida walked the facility inside and outside to ensure all passageways, and other areas of potential hazard are free of obstruction. LPA observed the kitchen and dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. LPA observed the fire extinguisher(s), smoke and carbon monoxide detectors and pull alarm system. Facility also has central heating and air.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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