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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
507203017
Report Date:
07/19/2024
Date Signed:
07/23/2024 09:13:25 AM
Document Has Been Signed on
07/23/2024 09:13 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:
MODESTO RESIDENTIAL LIVING CENTER, LLC
FACILITY NUMBER:
507203017
ADMINISTRATOR/
DIRECTOR:
DENNIS MONTEROSSO
FACILITY TYPE:
735
ADDRESS:
1932 EVERGREEN AVE
TELEPHONE:
(209) 530-9300
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95350
CAPACITY:
100
CENSUS:
87
DATE:
07/19/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:
Health Care Coordinator Carolyn Recio
TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a proof of correction (POC) visit. LPA Lund met with Health Care Coordinator Carolyn Recio and explained the reason for the visit. Census: 87
LPA Lund received proper POC documentation for the deficiency cited on 7/8/2024.
No deficiencies were observed and cited during this visit.
Exit interview conducted and report left.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Jason Lund
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/19/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/19/2024
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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