507005500-7-3-2025-27-AS-ELIM-DJ8SVE-20250703141236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507005500
Report Date: 07/03/2025
Date Signed: 07/03/2025 02:13:18 PM

Document Has Been Signed on 07/03/2025 02:13 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:	HUMMINGBIRD COURT CARE HOME		FACILITY NUMBER:	507005500
ADMINISTRATOR/ DIRECTOR:	ESCORIDO, ROSELYN		FACILITY TYPE:	735
ADDRESS:	3124 HUMMINGBIRD CT		TELEPHONE:	(209) 577-5830
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY: 6		CENSUS:	DATE:	07/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Roselyn Escorido, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:15 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	At 10:00 AM on 07/03/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection and was greeted by Staff Member #1 (S1). The LPA identified herself, explained the purpose of the visit, and asked to meet with the Administrator. S1 called the Administrator to notify her of LPA’s arrival and today’s annual inspection. The Administrator arrived at the facility at 10:45 AM. The LPA interviewed the Administrator, who then accompanied the LPA on a tour of the physical plant. The CARE inspection tool was used during this inspection. This facility is a residential house with four bedrooms and two bathrooms for clients, a living room, a dining room, a kitchen, a laundry room, and two staff rooms. It is licensed to serve 6 non-ambulatory clients, ages 18 to 59 years old. The majority of the clients have lived at the facility long-term. The current census was 5 clients; three clients were present at the time of this visit. There were two staff members on-duty. RECORDS REVIEW: The LPA requested records for the facility, staff, and residents. The LPA reviewed staff records and confirmed that all staff associated with the facility have a criminal background clearance, including the two staff on-duty during the site visit. The LPA also observed proof of required training and valid First Aid/CPR certificates for these staff. The LPA then reviewed resident records and observed that five out of five had appraisals, signed admission agreements, and physician’s reports. The facility had an emergency and disaster plan that was reviewed by all staff during an in-service held every six months. The LPA observed a log that documented the fire drills that were held on a monthly basis. This report continues on LIC809-C, page 2.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: HUMMINGBIRD COURT CARE HOME	FACILITY NUMBER: 507005500
	VISIT DATE: 07/03/2025

NARRATIVE

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BEDROOMS: The LPA toured the four client bedrooms, which were located to the right of the entry hall. Two bedrooms are single occupancy and two bedrooms are double occupancy. The bedrooms each contained the required furniture, including beds, bedside tables, and clothes dressers. The bedrooms were clean and odor-free, and in good repair. The closets contained clients' personal belongings and were clean and pest-free. The décor of each bedroom was personalized with client belongings. Each bedroom had an exit to the outside.

HALLWAY: The LPA toured the hallway. The hallway contained a linen closet with the required extra bedding and towels. The thermostat was located in the hallway and set at 76 degrees Fahrenheit (F). A smoke alarm was on the ceiling of the hallway. The Administrator tested the alarm, which sounded the alarm for it and the four connected alarms in each bedroom. A bulletin board on the wall contained the facility license, personal rights, emergency disaster plan, house rules, and menu.

BATHROOM #1: The LPA toured the bathroom located in the hallway. The bathroom is divided into two separate rooms. One room contained a shower with a slight ramp leading into it. The second room contained the toilet and sink. Both rooms were clean and odor-free. The hot water temperature at the bathroom sink was 109 degrees F. There were sturdy grab bars in the shower and near the toilet, and non-slip flooring in the shower.

LIVING ROOM: The LPA toured the living room. The living room contained two couches, a television set, and side tables. The fireplace was screened off. On either side of the fireplace were cabinets and shelves that stored facility records and the fire extinguisher. The fire extinguisher was serviced on April 1, 2025. There was artwork and a photo montage of clients hanging on the wall. A sliding glass door leads to the back yard and lets in natural light. The room was clean.

DINING ROOM: The LPA toured the dining room. The dining room was connected to the kitchen. It contained a table and chairs and had artwork on the wall. The room was clean and odor-free.

This report continues on LIC809-C, page 3.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025

LIC809 (FAS) - (06/04)

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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: HUMMINGBIRD COURT CARE HOME	FACILITY NUMBER: 507005500
	VISIT DATE: 07/03/2025

NARRATIVE

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KITCHEN: The LPA toured the kitchen. The counters, cabinets, sink, floor, and appliances were clean, operable, odor-free, and pest-free. There was enough plateware and cutlery for all residents. The LPA inspected the food supply located in the refrigerator, freezer, and pantry. There was additional food in a freezer located in a staff room.There was a wide variety of food and fresh fruit located on the counters. The facility had a two day supply of perishable food and seven day supply of non-perishable food. Sharp objects were stored in a locked drawer opened with a key.

CENTRAL MEDICATION STORAGE: The LPA inspected the central medication storage area, which was located in a locked cabinet in the kitchen. The LPA observed separate containers for each resident’s medication. All medicine was in its original containers with unaltered labels. The facility used a paper based Medication Administration Record (MAR), which staff initials after assisting with medicine administration. The first aid kit was stored in the medication cabinet and contained all the required items.

LAUNDRY ROOM: The LPA inspected the laundry room, located off a small hallway off the kitchen. The laundry room contained the washer and dryer, a utility sink, and the water heater. The toxic chemicals and cleaners were stored in this room. There was a door that led to the outside of the house.

STAFF ROOMS: The LPA inspected two staff rooms, which were located off this small hallway. The rooms contained staff items and stored material.

BATHROOM #2: The LPA inspected a second bathroom located off this small hallway. The bathroom contained a sink and bathtub with shower. The room is clean and odor-free.

BACKYARD: The LPA toured the backyard. The LPA observed a shaded area with chairs and a table on a wooden deck right outside the sliding glass doors. There was a ramp that led down to a paved area. The vegetation was maintained, the yard was clean, and there were no obstructions. There were two sheds with locks on the doors that contained client belongings. The LPA observed a large vegetable garden, including eggplant and tomatoes. The wooden side gate has a latch that secures the gate when closed.

This report continues on LIC809-C, page 4.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025

LIC809 (FAS) - (06/04)

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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: HUMMINGBIRD COURT CARE HOME	FACILITY NUMBER: 507005500
	VISIT DATE: 07/03/2025

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OTHER: The clients have monthly meetings, during which time they give their input for next month’s menu. Clients choose the activities they enjoy. Activities include going to the movie theater, park, mall, or bowling alley.

The LPA requested that updated copies of these documents be submitted to Licensing by 5:00 PM on 07/17/2025. These documents can be emailed to LPA at ellen.lindstrom@dss.ca.gov.

(1) LIC 308 Designation of Facility Responsibility
(2) Copy of a current Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Liability Insurance
(6) LIC 500 Personnel Report
(7) LIC 309 Administrative Organization

As a result of this inspection, no deficiencies were cited. The facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6.

An exit interview was conducted with the Administrator, to whom a copy of this LIC809 report was provided. Their signature below confirmed receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025

LIC809 (FAS) - (06/04)

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