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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203035
Report Date: 03/30/2022
Date Signed: 03/30/2022 03:13:21 PM

Document Has Been Signed on 03/30/2022 03:13 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:FAIRMONT RESIDENTIAL CAREFACILITY NUMBER:
507203035
ADMINISTRATOR:ESCORIDO, ROSELYNFACILITY TYPE:
735
ADDRESS:802 FAIRMONT AVETELEPHONE:
(209) 846-0692
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 5DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Caregiver Estrelita Alconis TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the above facility unannounced to conduct an Annual Required Inspection. LPA met with caregiver Estrelita Alconis who called Administrator Roselyn Escorido and explained the purpose of the visit. Administrator Roselyn Escorido could not make the visit and gave permission for caregiver Estrelita Alconis to sign required paperwork.

LPA Lund and caregiver Estrelita Alconis walked the physical plant including but not limited to the kitchen, dining room, client bedrooms; client bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies.

Fire extinguishers and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to clients. LPA observed carbon monoxide detectors in the facility.


Based on today's visit no deficiencies were observed or cited pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code.

Exit interview conducted with Administrator Roselyn Escorido conducted over the phone and a copy of report left at facility.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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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