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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203017
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:53:58 PM

Document Has Been Signed on 09/15/2022 02:53 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: 88DATE:
09/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administratrive Assistant Meisha Mcdonald TIME COMPLETED:
03:15 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 one Unusual/Incident reports (LIC624) that one client (C1) had went AWOL from the facility on 9/13/2022. C1 is able to leave the facility unassisted according to the clients LIC602. The facility filled police report for C1. C1- MD22018809. C1 has been found on 9/14/2022 is being evaluated and will be pick up after the evaluation.

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: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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