<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203035
Report Date: 09/11/2023
Date Signed: 09/11/2023 02:31:06 PM

Document Has Been Signed on 09/11/2023 02:31 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: 4DATE:
09/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Caregiver Estrelita Alconis TIME COMPLETED:
03:15 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 Jason Lund arrived unannounced to the facility to conduct a case management visit. LPA Lund met with Caregiver Estrelita Alconis and explained the reason for the visit. LPA Lund spoke with Administrator Roselyn Escorido who gave permission for Caregiver Estrelita Alconis to sign required paperwork.

On 8/4/2023, the Sacramento Adult and Senior Care Regional Office, received an Unusual/Incident report from the facility reporting the death of resident (R1). The Regional Office obtained the medical records and the death certificate for R1.

Medical records show R1 arrived at Doctors Medical Center on 7/30/2023, at approximately 0220 hours. R1 transitioned to comfort care and expired on 7/30/2023, at 1844 hours. There was no mention of any abuse or neglect in any of the medical records.

No deficiencies cited during this visit. Exit interview conducted & copy of this report provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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 1