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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 575001676
Report Date: 06/25/2021
Date Signed: 06/25/2021 03:54:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MODERN CARE AND LIVING, LLCFACILITY NUMBER:
575001676
ADMINISTRATOR:SILVESTRE, RAMONFACILITY TYPE:
740
ADDRESS:2472 STARLING LANETELEPHONE:
(916) 239-8948
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:6CENSUS: 2DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Lead Staff, Elizabeth AndersonTIME COMPLETED:
04:10 PM
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Licensing Program Analysts (LPA) Katrina Walters arrived unannounced to conduct an Annual Required inspection and met with Lead Staff, Elizabeth Anderson (EA). Administrator/Licensee Ramon Silvestre was not available for today's visit. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. LPA conducted a Risk Assessment with Administrator prior to entering the facility.

Upon entry, LPA signed into facility sign-in sheet and had temperature checked and logged into a binder. LPA discussed with EA and Administrator to document COVID-19 screening questionnaire for visitors to the facility. LPA advised that the screening questions be added to the sign in sheet. EA stated that the screening questions were removed when cleaning the facility. LPA conducted a walk-through of the facility with staff. The facility was clean and a comfortable temperature. Per staff the facility is disinfected twice daily. LPA observed that proper signage was posted throughout the facility to promote hand washing. Each resident has a designated visitation area. Facility has a 60+ day supply of PPE. Facility has a 30-day supply of medication for residents. LPA advised that all staff be fit tested for N95 mask. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 to the California Department of Social Services and it was approved on 6/9/21.

LPA advised the following during today's visit: Complete N-95 Fit Testing for all staff and Add a field on sign-in sheet so visitors can conduct screening.

Exit interview conducted with lead staff, whose signature on this document confirms receipt. LPA went over the report with Administrator via phone. No deficiencies cited during this inspection




SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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