507203017-10-18-2023-27-AS-RWAE-CWQRSV-20231018131722

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507203017
Report Date: 10/18/2023
Date Signed: 10/18/2023 01:17:27 PM

Document Has Been Signed on 10/18/2023 01:17 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, LLC		FACILITY NUMBER:	507203017
ADMINISTRATOR:	DENNIS MONTEROSSO		FACILITY TYPE:	735
ADDRESS:	1932 EVERGREEN AVE		TELEPHONE:	(209) 530-9300
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY: 100		CENSUS: 87	DATE:	10/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Facility Manager - Lena Baldwin		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection visit. LPA met with facility manager and explained the purpose of today's visit. LPA and facility manager toured/Inspected the facility and observed the living room area in a sanitary condition with required furnishings and lighting. The activity room has a large television screen in the room and comfortable furniture. The facility has two telephones, one upstairs and downstairs. The facility was equipped with smoke and carbon monoxide detectors that met regulation requirements. Fire extinguishers were last inspected on 8/10/2023. There was a board that displayed all documents required from the Department. The laundry room was viewed as well as staff member doing laundry. LPA observed some rooms that were clean and well maintained. The facility submitted a LIC 808 mitigation plan, which was approved. The kitchen was found in a sanitary condition and held required two day perishable and seven day non-perishable food supplies. Water temperature reads 113.7*F in the kitchen sink which meets the 105-120 degree Fahrenheit regulation. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Facility has an emergency food and water kit. Continued on 809-C Page 2

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, LLC	FACILITY NUMBER: 507203017
	VISIT DATE: 10/18/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from 809 - Page 2

LPA reviewed five staff and five resident files that were locked and readily available for review. Staff had current First Aid/CPR certificates All staff have criminal record clearance and are associated to the facility.

LPA received the following updated documents on today's date: LIC 308 Designation of Responsibility. LIC 500 Personnel Report, and copy of surety bond.

LPA viewed the garage in the back yard that contained canned foods. There was four gallon jugs of motor oil unlocked outside of the garage. Staff locked up the motor oil jugs immediately after LPA pointed them out to him.

Per the California Code of Regulations, Title 22 see 809-D for deficiency cited and observed.

Exit interview was completed with facility manager. A copy of LIC 811 (Confidential Names), LIC 809, LIC 809-C, LIC 809-D, and appeal rights was provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 10/18/2023 01:17 PM - It Cannot Be Edited

Created By: Ruth Wallace On 10/18/2023 at 01:00 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: 10/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)(1)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in there were four one gallon jugs of motor oil outside of the garage, unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2023
	Plan of Correction
1 2 3 4	Licensee locked up the four jugs of motor oil immediately and LPA observed them being locked up. No further action required. Plan of Correction letter will be printed and cleared on 10/18/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Stephen Richardson

LICENSING EVALUATOR NAME:

Ruth Wallace

LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3