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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203035
Report Date: 03/28/2024
Date Signed: 03/28/2024 01:18:46 PM

Document Has Been Signed on 03/28/2024 01:18 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: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:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Roselyn EscoridoTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an Annual/Required Inspection. LPA met with Caregiver who called Administrator Roselyn Escorido who showed a short time later. LPA Lund explained the purpose of the visit to Administrator Roselyn Escorido. Census: 5

LPA Lund and Administrator Roselyn Escorido who toured/inspected 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. LPA Lund reviewed three staff files and three clients files are were in compliance.

No deficiencies were observed during this visit. Exit interview conducted with Administrator Roselyn Escorido and report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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