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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203017
Report Date: 03/12/2025
Date Signed: 03/12/2025 10:07:50 PM

Document Has Been Signed on 03/12/2025 10:07 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: 84DATE:
03/12/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator Assistant Lionel Bazan TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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LPA Jason Lund arrived unannounced to complete a case management visit. LPA Lund met with Administrator Assistant Lionel Bazan and explained the purpose of today's visit. Census: 84

On 12/12/24 the facility hallway 3 heating and air conditioning system went out and the facility failed to do an Unusual Incident/ Injury (LIC624) to Community Care Licensing. The facility is repairing the system at this time.

Exit interview held with Administrator Assistant Lionel Bazan. Deficiencies cited on the attached 809D. Report & appeal rights given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/12/2025 10:07 PM - It Cannot Be Edited


Created By: Jason Lund On 03/12/2025 at 02:13 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2025
Section Cited
CCR
80061(b)(1)(E)

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(b)Upon the occurrence…of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day… In addition, a written report…shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Licensee will go over the regulation with management and email LPA Lund that they understand the regulation.
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This requirement was not met as evidenced by: Based on interview and record review, Licensee did not ensure the timely report of heating system going out at the facility per regulatory requirements. This posed a 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:Lisa Rios
LICENSING EVALUATOR NAME:Jason Lund
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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