<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005425
Report Date: 07/29/2024
Date Signed: 07/30/2024 09:29:52 AM


Document Has Been Signed on 07/30/2024 09:29 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 4DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Sajida Khan TIME COMPLETED:
03:30 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
Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a Required Annual Inspection. LPA was met by Administrator Sajida Khan and explained the reason for the visit. Census: 4

LPA Lund & Administrator Sajida Khan toured/inspected 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, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. The temperature inside the building measured at 74.0 *F which is within the required range of 68-85*F. The hot water temperature was measured higher than normal and the maintenance was working on their system to maintain the required temperature of 105-120. LPA observed 2-day perishable and 7- day non-perishables during this visit. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution. LPA observed the fire extinguisher(s) (3/4/2024), smoke and carbon monoxide detectors and pull alarm system. Facility also has central heating and air. LPA Lund reviewed 2 resident files and 2 staff files were reviewed during this visit.

No violations were observed during this visit. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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 1