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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203017
Report Date: 10/23/2024
Date Signed: 10/23/2024 08:49:20 PM

Document Has Been Signed on 10/23/2024 08:49 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/
DIRECTOR:
PATRICIA A CALLAFACILITY TYPE:
735
ADDRESS:1932 EVERGREEN AVETELEPHONE:
(209) 530-9300
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 100CENSUS: 86DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Assistant Administrator Lionel BazanTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a one year annual/required visit. LPA met with Assistant Administrator Lionel Bazan and explained the reason for the visit. Census: 86
LPA Lund and Assistant Administrator Lionel Bazan toured/Inspected the facility and observed the living room area in a sanitary condition with required furnishings and lighting. The activity room has a large television 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 last inspected on 8/09/2024. There was a board that displayed all documents required from the Department. The laundry room was viewed. LPA observed some rooms that were clean and well maintained. The kitchen was found in a sanitary condition and held required two- day perishable and seven -day non-perishable food supplies. Water temperature reads 112.3*F in the kitchen sink which meets the 105–120-degree Fahrenheit regulation. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Facility has an emergency food and water kit. LPA Lund & Assistant Administrator Lionel Bazan toured the outside of the facility to be clean and be used by clients in care. LPA reviewed four staff and eight resident files that were locked and readily available for review. Staff had current First Aid/CPR certificates. All staff have criminal record clearance and are associated to the facility.
Per the California Code of Regulations, No deficiencies were cited during today’s visit. Exit interview was completed and report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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