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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203017
Report Date: 10/15/2021
Date Signed: 10/15/2021 03:09:30 PM

Document Has Been Signed on 10/15/2021 03:09 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:MODESTO RESIDENTIAL LIVING CENTER, LLCFACILITY NUMBER:
507203017
ADMINISTRATOR:DENNIS MONTEROSSOFACILITY TYPE:
735
ADDRESS:1932 EVERGREEN AVETELEPHONE:
(209) 530-9300
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 100CENSUS: 93DATE:
10/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrative Assistant Christian JacksonTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jason Lund made an unannounced visit to conduct a required annual inspection. LPA Lund met with Administrative Assistant Christian Jackson and explained the purpose of today's visit.

LPA Lund and Administrative Assistant Christian Jackson walked the facility and observed the living room area in a sanitary condition with required furnishings and lighting. The activity room has a large TV screen in the room and comfortable furniture. The facility has two telephones, one upstairs and downstairs. The facility was equipped with smoke and carbon monoxide detectors that met regulation requirements. Fire extinguishers were correctly installed and serviced. There was a board that displayed all documents required from the Department.

The kitchen was found in a sanitary condition and held required 2- day perishable and 7- day non- perishable food supplies. LPA Lund viewed the garage in the back yard that contained canned foods. Toxic materials were present but placed at a distance not to contaminate food. The laundry room was viewed as well as staff member doing laundry. LPA Lund observed some rooms that were clean and well maintained.

No deficiencies were observed during today annual required visit. Exit interview was done with Administrative Assistant Christian Jackson and a copy of the report, was provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
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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