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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203017
Report Date: 10/15/2021
Date Signed: 10/15/2021 03:33:47 PM

Document Has Been Signed on 10/15/2021 03:33 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:
10/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrative Assistant Christian Jackson TIME COMPLETED:
03:30 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 Christian Jackson and explained the purpose of today's visit.

Community Care Licensing received a complaint for the facility on 8/3/2021 during the complaint investigation there was an incident with client (C1) that was brought to licensing attention. C1 had fallen in the front of the facility and broke C1’s arm. While C1 was at the hospital C1 caught COVID-19 and passed away. The facility never turned in Unusual incident/ injury report for the fall for C1 or death report for C1 passing away at the hospital.

During the investigation into the complaint on 8/3/2021 the facility had eleven in-house reports regarding client C2’s behaviors of touching people inappropriately. The facility management failed to turn Unusual incident/ injury report for the eleven incidents reports to Community Care Licensing (CCL) or the Local Police Department about C2’s behaviors.

Based on record reviewed, the following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrative Assistant Christian Jackson and a copy of this report was provided along with confidential names list and appeal rights.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
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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Document Has Been Signed on 10/15/2021 03:33 PM - It Cannot Be Edited


Created By: Jason Lund On 10/15/2021 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MODESTO RESIDENTIAL LIVING CENTER, LLC
FACILITY NUMBER: 507203017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2021
Section Cited
CCR
80061(E)

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Reporting Requirements
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
This requirement is not met as evidenced by:
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Plan of Correction Management will work with staff on what to report to CCL & Local PD. Will email copy LPA Lund when done.
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Based on investigation for an complaint on 8/3/2021 the facility failed to send an incident reports to CCL. This violation poses an potential health, and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Jason Lund
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021


LIC809 (FAS) - (06/04)
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