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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203017
Report Date: 07/05/2023
Date Signed: 07/05/2023 03:48:09 PM

Document Has Been Signed on 07/05/2023 03:48 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: 85DATE:
07/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Facility Manager Christian JacksonTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Jason Lund & Licensing Program Manager Stephen Richardson arrived unannounced to conduct a case management visit. LPA Lund was met with Facility Manager Christian Jackson and explained the reason for the visit.

LPA Lund received a death report on 7/2/23 that client (C1) passed away. On 7/2/2023 C1 was found unresponsive on the 2nd floor with no pulse. LPA Lund is requesting a copy C1 file..

No deficiencies were observed during today visit. Exit interview conducted with Administrative Assistant Christian Jackson and a copy left.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2023
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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