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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701366
Report Date: 03/27/2024
Date Signed: 04/05/2024 02:08:31 PM

Document Has Been Signed on 04/05/2024 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:CVR HOME CARE LLCFACILITY NUMBER:
502701366
ADMINISTRATOR:TUDENCE, SHIRLEYFACILITY TYPE:
740
ADDRESS:709 NORTHWOOD DRIVETELEPHONE:
(209) 200-0523
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 0DATE:
03/27/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Licensee Claire RabangTIME COMPLETED:
01:15 PM
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Announced prelicensing visit was made by LPA Lund. LPA Lund met with applicant, Applicant Shirley Tudence and Licensee Claire Rabang explained the reason for the visit. Census: 0

The facility will be licensed to serve up to (6) residents at any given time. This Applicant is seeking a facility with six nonambulatory residents. LPA Lund, Applicant Shirley Tudence and Licensee Claire Rabang tour/inspected the facility. LPA inspected the dining area, living area, and all other areas intended for resident use. LPA observed to be furnished and maintained in compliance at this time. The Facility had a Medication cabinet (locked) were medication will be stored. First aid kit was observed in the Medication cabinet to be present and contained all required components at this time. A tour of the (4) resident bedrooms, was conducted with two shared & two individual rooms. Furnishings intended for use by the residents were observed to meet the needs of the residents at this time. The facility also had two bathrooms for the residents. One bathroom is in a room for one individual. The facility has one room for staff use with a bathroom.A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. The facility has one fire extinguisher that and carbon monoxide are in compliance. The has a working telephone.

This facility has been found to be in compliance at this time.
Applicant Shirley Tudence and Licensee Claire Rabang completed the Component 111 requirements. Exit interview and report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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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