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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203035
Report Date: 08/03/2023
Date Signed: 08/03/2023 01:22:49 PM

Document Has Been Signed on 08/03/2023 01:22 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: DATE:
08/03/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:TIME COMPLETED:
01:15 PM
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Licensing Program Analyst Albert Johnson met with Staff to conduct a health check care.

The Department conducted a case management visit for a health and safety check. R1 was in bed when the safety check was completed.

LPA Lund received documents on 8/2/23.
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Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were observed during this visit.

Exit interview held.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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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