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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700317
Report Date: 07/23/2024
Date Signed: 07/23/2024 12:05:05 PM


Document Has Been Signed on 07/23/2024 12:05 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 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:
07/23/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator, Nelson Jacinto TIME COMPLETED:
12:20 PM
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On 07/23/24, 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 toured the facility and observed that Resident Room #9 bathroom still was in disrepair as the shower has a leak and is inoperable.The ceiling and wall of the bathroom has what appears to be water damage. On 06/20/2024 ,07/09/24 and 07/16/24 , LPA Bains spoke to the licensee who stated the facility would ensure the bathroom would be fixed. As of this date, there might be follow up but restroom is still inoperable.

Due to this issue, 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. LPA conducted POC visit to facility on 07/16/24 and Civil Penalty was assessed of $ 100/day from 07/10/24 -07/16/24 but facility did not comply with POC requirements till date, therefore,on today's date, LPA will be assessing a Civil Penalty of $100/day from 07/17/24- 07/23/24 ,total of $700 for this violation and will continue to accrue until POC is corrected.

LPA informed administrator that Department is inviting administrator for Informal Department Meeting which will be held at 9835 ,Goethe Road #100, Sacramento, CA,95827 on 07/31/24 at 10AM and attendance is Mandatory to discuss on going issues with facility and administrator stated that they understood and accepted the meeting invite.

Civil Penalties were assessed during this visit for failure to correct the above violation 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: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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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