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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203017
Report Date: 02/29/2024
Date Signed: 02/29/2024 02:46:27 PM

Document Has Been Signed on 02/29/2024 02:46 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:DENNIS MONTEROSSOFACILITY TYPE:
735
ADDRESS:1932 EVERGREEN AVETELEPHONE:
(209) 530-9300
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 100CENSUS: 89DATE:
02/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Steve Bryant TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a case management visit. LPA Lund met with Administrator Steve Bryant and explained the purpose of today's visit.

Community Care Licensing has received one Unusual/Incident reports (LIC624) that one client (C1) had went AWOL from the facility on 2/13/2024. C1 is able to leave the facility unassisted according to the clients LIC602 dated 8/15/2023. The facility filled police report for C1.MD24003224. C1 has returned to the facility on 2/14/2024. Staff are doing half hour checks on C1.

No deficiencies were observed during today visit. Exit interview done and a copy of the report, was left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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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