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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701153
Report Date: 05/19/2022
Date Signed: 05/19/2022 03:21:27 PM

Document Has Been Signed on 05/19/2022 03:21 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 HOME 2FACILITY NUMBER:
502701153
ADMINISTRATOR:PAYLA, MARIA ALONAFACILITY TYPE:
740
ADDRESS:518 WEST GRANGER AVENUETELEPHONE:
(209) 204-9794
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 5CENSUS: 0DATE:
05/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ms. PaylaTIME COMPLETED:
03:30 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
Licensee Program Analyst Jason Lund met with applicants and Licensee Maria Payla and Peter Yu to conduct a Pre- Licensing inspection for this new elderly care home applicant.

LPA toured the facility including common areas, resident bathrooms, kitchen, dining room, laundry, storage, and outside yard area. Requested capacity is 5 clients. 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. A Fire Clearance was granted for 5 non-ambulatory clients.

Adequate number of bedrooms/apartments for capacity requested. Physical plant appears consistent with facility sketch. Facility has supply of bedding and towels. Furniture appears appropriate in bedrooms. There is adequate closet/drawer space available. There are plenty of bathrooms for number of residents. Non-skid mats will be purchased for the two showers. Emergency lighting available. Kitchen appears to be clean, well-supplied with equipment. Cooler/freezer appear to be at appropriate temperatures. First aid supplies available in several locations. Laundry equipment present, working telephone, emergency lighting.

Component III was provided. LPA reviewed Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medications Procedures.
Exit interview conducted and copy of this report given to Ms. Payla.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
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