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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203017
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:59:09 PM

Document Has Been Signed on 12/17/2021 02:59 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: 89DATE:
12/17/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrative Assistant Christian JacksonTIME COMPLETED:
03:00 PM
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LPA Jason Lund arrived at the above facility unannounced to complete an Proof of Correction (POC) visit. LPA Lund met with Administrative Assistant Christian Jackson and explained the purpose of today's visit.

On 7/21/21 the facility was cited for AWOL procedures and on 10/15/21 the facility was cited for Reporting requirements.

On 10/11/21 the facility had training with Staff on the two deficiencies. This cleared the corrections (POC) for the facility.

An exit interview was conducted with Administrative Assistant Christian Jackson and a copy of this report was provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
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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