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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700317
Report Date: 07/31/2024
Date Signed: 07/31/2024 11:01:31 AM


Document Has Been Signed on 07/31/2024 11:01 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:
07/31/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Nelson Jacinto TIME COMPLETED:
11:00 AM
NARRATIVE
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On 07/31/2024 at 10:00AM, an informal conference was conducted at Sacramento Regional Office. The purpose of this informal conference meeting is to discuss the deficiencies observed within last 3 years and to address current issues at facility. Present in the meeting were, Licensing Program Manager (LPM) Laura Munoz and Troy Ordonoz, Licensing Program Analysts (LPAs) Talwinder Bains and Graham Gunby, and licensee/administrator, Nelson Jacinto.

The informal conference process was explained during this meeting.

Issues discussed during the meeting were:
- Resident’s care and supervision
- Dietary services
- Resident’s Personal Rights
- Facility’s Operation and Maintenance
- Residents Activities Services
- Multiple civil penalties assessed within last 3 months for Failure to comply with POC Requirements

The facility has stated they will do the following to achieve continued and substantial compliance:
• Submit a letter of understanding of Title 22 by 08/15/24
• Reach out to Community Care Licensing Division (CCLD) as a resource.

Technical Support Program (TSP) was offered and accepted.

Deficiencies were cited per Title 22 Regulations. Exit interview conducted. Informal meeting concluded,Appeal Rights and a copy of report was provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
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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Document Has Been Signed on 07/31/2024 11:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GRACE HOME II
FACILITY NUMBER: 342700317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2024
Section Cited
CCR
87405

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87405-Administrator - Qualifications and Duties- (d) The administrator shall have the qualifications .......If the licensee is also the administrator, all requirements for an administrator shall apply.(1) Knowledge of the requirements ......(2)Knowledge of and ability to conform to the applicable laws, rules and regulations……this requirement is not met as evidence by;
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Licensee shall hire a qualified administrator and shall notify Department when hired. All POC documents are due by POC date-09/15/24.
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Based on facility's observations and staff's interviews, facility does not have a qualified Administrator which poses health and safety risks to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
LIC809 (FAS) - (06/04)
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