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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700317
Report Date: 07/16/2024
Date Signed: 07/16/2024 11:04:36 AM


Document Has Been Signed on 07/16/2024 11:04 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GRACE HOME IIFACILITY NUMBER:
342700317
ADMINISTRATOR:NELSON JACINTOFACILITY TYPE:
740
ADDRESS:9260 LOMA LANETELEPHONE:
(916) 607-6225
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:24CENSUS: 22DATE:
07/16/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Administrator, Nelson Jacinto TIME COMPLETED:
11:15 AM
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On 07/16/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a Plan of Correction (POC) case management and met with Administrator, Nelson Jacinto . LPA met with administrator in the parking lot as administrator was leaving with a resident for their doctor's appointment. LPA explained the purpose of the visit. Administrator stated that they were aware that facility did not comply with POC requirements from 07/09/24 visit as things were really busy with them and facility. Administrator stated that facility will send all required POC documents but did not provide any time frame. Administrator stated that Staff ,Maria Segarra (Cory) will assist LPA with today's visit and can sign today's report's documents.

On 07/09/24, LPA cited the facility on CCR regulation, 87468.1 (a)(6) -Personal Rights of Residents in All Facilities -and facility should have submitted all required documents to clear POC by POC Due Date of 07/10/24. Licensee/administrator did not ensure that the POC was corrected upon Due Date of 07/10/24. On today's date, LPA will be assessing a Civil Penalty of $100/day from 07/10/24- 07/16/24 for this violation and will continue to accrue until POC is corrected.

On 07/09/24, LPA cited the facility on CCR regulation, 87468(a)(13)- Personal Rights of Residents in All Facilities- and facility should have submitted all required documents to clear POC by POC Due Date of 07/10/24. Licensee/administrator did not ensure that the POC was corrected upon Due Date of 07/10/24. On today's date, LPA will be assessing a Civil Penalty of $100/day from 07/11/24- 07/16/24 for this violation and will continue to accrue until POC is corrected.

On 07/09/24, LPA cited the facility on CCR regulation, 87303(a)- Maintenance and Operation-and facility should have submitted all required documents to clear POC by POC Due Date of 07/10/24. Licensee/administrator did not ensure that the POC was corrected upon Due Date of 07/10/24. On today's date, LPA will be assessing a Civil Penalty of $100/day from 07/11/24- 07/16/24 for this violation and will continue to accrue until POC is corrected.

Civil Penalties were assessed during this visit for failure to correct the above violations by POC Due Date. Exit Interview was conducted, Appeal rights were provided, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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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