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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203017
Report Date: 03/27/2024
Date Signed: 03/27/2024 09:07:44 PM

Document Has Been Signed on 03/27/2024 09:07 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: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: 87DATE:
03/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Assistant Administrator Lionel BazanTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a case management visit. LPA Lund met with Assistant Administrator Lionel Bazan and explained the purpose of today's visit.

Community Care Licensing received an Unusual/Incident reports (LIC624) that one client (C1) was sent Doctor’s Medical Center on 3/13/2024 for having aggressive behaviors towards staff and clients in care. No clients in care are staff were hurt during C1 behaviors. C1 conservator was notified of the incident. C1 was medically cleared and transferred to Doctors Behavior Health Center and has not yet returned to the facility.

No deficiencies were observed during today visit. Exit interview done and a copy of the report, was left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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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