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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
507203017
Report Date:
02/15/2024
Date Signed:
02/15/2024 07:01:27 PM
Document Has Been Signed on
02/15/2024 07:01 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, 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:
89
DATE:
02/15/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
02:00 PM
MET WITH:
Assistant Administrator Lionel Bazan
TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an proof of correction (POC) visit. LPA Lund was met with
Assistant Administrator Lionel Bazan
and explained the reason for the visit.
LPA Lund visited the facility on 12/6/2023 and citied the facility for having bed bugs and on 2/15/2024 LPA Lund cleared the deficiency with a visit. LPA Lund visited the facility on 1/26/2924 and citied the facility for two deficiencies staff administered a medication the resident has an allergy to & staff does not ensure facility is free of pests on 2/152024 LPA Lund cleared both of these deficiencies with a visit on 2/15/2024.
No deficiencies were observed during today visit. Exit interview conducted with
Assistant Administrator Lionel Bazan
and a copy left.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Jason Lund
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/15/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/15/2024
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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