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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701366
Report Date: 05/21/2024
Date Signed: 05/21/2024 12:56:01 PM

Document Has Been Signed on 05/21/2024 12:56 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/
DIRECTOR:		TUDENCE, SHIRLEYFACILITY TYPE:
740
ADDRESS:709 NORTHWOOD DRIVETELEPHONE:
(209) 200-0523
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 1DATE:
05/21/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Licensee Claire Rabang TIME VISIT/
INSPECTION COMPLETED:
01:30 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
Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an post-licensing visit. LPA Lund met with staff and later with explained the reason for the visit. Census: 1

LPA Lund & 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) and stored. First aid kit was observed in the Medication cabinet to be present and contained all required components at this time. LPA inspected four (4) residents bedrooms, with two shared & two individual rooms. Furnishings for 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. 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. The facility has 7-day non-perishable and 2-day perishable foods. LPA Lund reviewed 1 resident file and two staff files and were in compliance at this time.

No deficiencies cited on this visit and report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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