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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700438
Report Date: 08/25/2021
Date Signed: 08/25/2021 02:07:55 PM

Document Has Been Signed on 08/25/2021 02:07 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:ETERNITY CARE HOMEFACILITY NUMBER:
502700438
ADMINISTRATOR:PAYLA, MARIA ALONAFACILITY TYPE:
740
ADDRESS:1704 MOUNT VERNON DRTELEPHONE:
(209) 567-2812
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 4DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Maria Payla & Peter YuTIME COMPLETED:
02:00 PM
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Licensee Program Analyst Jason Lund met Licensee/Administrator Maria Payla and Peter Yu to conduct an annual and post licensing inspection for the facility.

LPA toured the facility including common areas, resident bathrooms, kitchen, dining room, laundry, storage, and outside yard area. The facility is clean and in good repair and no odors were detected in areas toured. No hazards were noted in courtyard areas, hallways, doorways, etc. No equipment was stored in public areas. Fixtures and furniture all appear to be in good condition. Cleaning solutions are stored separately from food. Handrails are present in all shower and toilet areas, are secured. Room temperature was comfortable in facility. There are no bodies of water on the premises.

No deficiencies were observed at this time.
Exit interview conducted and copy of this report given to Ms. Payla & Peter Yu.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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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