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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203017
Report Date: 05/31/2022
Date Signed: 05/31/2022 02:48:48 PM

Document Has Been Signed on 05/31/2022 02:48 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:
05/31/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrative Assistant Meisha McdonaldTIME COMPLETED:
03:00 PM
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LPA Jason Lund arrived at the above facility unannounced to complete a case management visit. LPA Lund met with Administrative Assistant Meisha Mcdonald and explained the purpose of today's visit.

Community Care Licensing has received two Unusual/Incident reports (LIC624) that two clients (C1 & C2) have went AWOL from the facility. C1 went AWOL on 5/28/2022 and C2 went AWOL on 5/29/2022. Both C1 & C2 were able to leave the facility unassisted according to the clients LIC602’s. The facility filled police reports for both incidents for C1 & C2. C1- MD22010876 & for C2- MD22010393. Since 5/31/2022 either client has been located.

No deficiencies were observed during today annual required visit. Exit interview was done with Administrative Assistant Meisha Mcdonald and a copy of the report, was provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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