507004556-6-12-2025-27-AS-APAA-DHKQ7D-20250612115458

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004556
Report Date: 06/12/2025
Date Signed: 06/12/2025 11:55:10 AM

Document Has Been Signed on 06/12/2025 11:55 AM - 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:	CASA DE LUZ		FACILITY NUMBER:	507004556
ADMINISTRATOR/ DIRECTOR:	JOHANNA WEST		FACILITY TYPE:	740
ADDRESS:	3509 SCENIC DR		TELEPHONE:	(209) 578-3077
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY: 6		CENSUS: 4	DATE:	06/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Terri Salcido		TIME VISIT/ INSPECTION COMPLETED:	12:15 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 this facility to conduct an annual visit. LPA met with saff member(SM), Terri Salcido and explained the purpose of the visit. LPA asked that SM Salcido call the Facility Designated Administrator (FDA), Johanna West that CCL was present at this time. It was learned that FDA was no longer with the company. Shortly after, LPA met with the new Facility Designated Administrator, Jamie Rolando Andrade and explained the purpose of the visit. This facility is licensed to serve up to 6 elderly residents. Current census was 4. Upon arrival LPA Pascua observed 1 resident sitting outside and 3 other playing a card game at the dining table. Shortly after, all residents went out on a walk with facility staff. LPA reviewed 4 resident files. LPA reviewed 4 staff files. LPA reviewed 4 staff files The FDA does not have an active administrator certificate on file at this time. However, LPA had advised for the following documentation to update the administrator: -A letter from the licensee appointing the individual as the Administrator. -LIC 308 -Copy of the current Administrator certificate -Documentation verifying that the individual meets education/experience -LIC 200 signed by the licensee -LIC 500 -LIC 501

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: CASA DE LUZ	FACILITY NUMBER: 507004556
	VISIT DATE: 06/12/2025

NARRATIVE

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A tour was initiated. Fire extinguisher was serviced by Jorgenson Co and is valid until 06/09/2026. Smoke alarms and carbon monoxide were in good repair.
It was observed that the facility has recently gone through major renovations, such as the facility bathrooms, resident bedrooms and back yard. It was observed that all resident bedrooms have been furnished with new bedroom furniture that meets the residents needs at this time.
Kitchen area was toured. It was observed that there was a 2 day perishable and 7 day nonperishable food supply. Toxins and knives were made inaccessible at this time.
Hot water was taken to ensure that it within the require regulatory standards between 105-120 degrees. Grab bars were present and in good repair.
All living areas, dining areas, and other areas intended for resident use were toured and met the residents needs at this time.
The garage area was toured, washer and dryer were identified. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Additional food supply was also observed.
A tour of the exterior physical plant was conducted. Perimeter fence, side gates, and exits was inspected and in good repair. It was observed that the facility was currently obtaining a new awning at this time.
Medications were reviewed. First aid kit was reviewed and held all the required components.

The following forms and documents were requested to be updated and submitted into CCL:
-LIC 308
-LIC 400
-LIC 500
-LIC 610
-Liability insurance

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, no deficiencies were observed. An exit interview was held, and a copy of the report was provided.

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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