502701246-6-12-2025-27-AS-APAA-DHKSSL-20250612140808

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701246
Report Date: 06/12/2025
Date Signed: 06/12/2025 02:08:16 PM

Document Has Been Signed on 06/12/2025 02:08 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:	DIGNITY POINT SENIOR HOME CARE, L.L.C.		FACILITY NUMBER:	502701246
ADMINISTRATOR/ DIRECTOR:	MOLINA, ROMMEL		FACILITY TYPE:	740
ADDRESS:	3708 BOLD RULER CT		TELEPHONE:	(408) 824-0488
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY: 6		CENSUS: 6	DATE:	06/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:25 PM
MET WITH:	Rommel Molina		TIME VISIT/ INSPECTION COMPLETED:	02:30 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	On 06/12/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Rommel Molina and explained the purpose of the visit. There was one other staff member present, Sheila Coronado. This facility is licensed to serve residents 60 and older, of which all 5 may be non-ambulatory and 1 may be bedridden in bedroom 4. This facility also holds a hospice waiver for 6 and has a dementia plan on file. Current census was 6. A brief interview with FDA Molina was conducted. LPA reviewed 6 resident files. 6 resident files were complete and up to date. The Facility Designated Administrator, Rommel Molina, hold a current and administrator certificate #67025966740 and expires on 09/28/2025. Tour of the facility was conducted. Carbon monoxide and smoke alarms were present and were in working condition. Common areas for resident use were toured. Furniture and furnishings were observed to be present and in compliance. A tour of the bathrooms was conducted. Hot water temperatures were taken to ensure that the hot water being dispensed was within the allowed range of 105-120 degrees at this time. Grab bars were present and functional. Resident bedrooms were toured. Furniture and furnishing were observed to be present and in good condition. A linen closet was located in the hallway. LPA observed a sufficient amount of linens at this time.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DIGNITY POINT SENIOR HOME CARE, L.L.C.	FACILITY NUMBER: 502701246
	VISIT DATE: 06/12/2025

NARRATIVE

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The kitchen area was toured. Facility freezer and refrigerator showed to be functional and in compliance at this time. A tour of the pantry was conducted. LPA observed that there was a 7-day nonperishable food supply at this time.
The fire extinguisher, located in the kitchen area, was purchased on 06/12/2025 with a receipt attached and is in compliance at this time.

Garage area was toured. LPA observed refrigerator unit which will store additional food supplies.
This facility has a centralized medication cabinet that was observed to be locked and made inaccessible to the residents.

First aid kit was observed to be present and contained all of the required components at this time.

Exterior grounds of this facility was toured.
Perimeter fence and gates were observed to be functional and in good repair at this time.

No deficiencies were observed or cited during this visit. Exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025

LIC809 (FAS) - (06/04)

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