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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
507203048
Report Date:
01/17/2024
Date Signed:
01/17/2024 11:46:44 AM
Document Has Been Signed on
01/17/2024 11:46 AM
- 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:
UNITED CEREBRAL PALSY OF STANISLAUS COUNTY
FACILITY NUMBER:
507203048
ADMINISTRATOR:
MARISOL MORENO
FACILITY TYPE:
775
ADDRESS:
4265 SPYRES WAY, SUITE #2
TELEPHONE:
(209) 577-2122
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95356
CAPACITY:
75
CENSUS:
42
DATE:
01/17/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:45 AM
MET WITH:
Program Manager Marisol Moreno
TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the day program unannounced to conduct case management visit. LPA Lund met with Program Manager Marisol Moreno and explained the reason for the visit.
On 1/5/2024 CCL received a Valley Mountain Regional Center Special Incident Report that Client (C1) had bruises in the stomach area. On 1/3/2024 the program received call from the family stating that C1 was in the hospital from 12/21/23 through 12/24/23 stating while at the hospital C1 was given medications (Shots) in the stomach area.
Exit interview conducted with Program Manager Marisol Moreno and a copy of this report was provided.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Jason Lund
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/17/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/17/2024
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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