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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700317
Report Date: 04/20/2023
Date Signed: 04/20/2023 12:02:12 PM


Document Has Been Signed on 04/20/2023 12:02 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 21DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Nelson Jacinto TIME COMPLETED:
11:30 AM
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 4/20/2023 , Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a Required- 1 Year inspection utilizing the inspection tool. LPA met with administrator ,Nelson Jacinto , and explained the purpose of the visit.

LPA toured the interior and exterior of the facility together with administrator to ensure the health and safety of residents in care. Areas toured include but are not limited to: residents' bedrooms, bathrooms, common areas, maintenance room, kitchen, courtyard, and medication room. LPA observed required furniture, and lighting throughout the residents' bedrooms. Bathrooms are clean, sanitary, and in good repair. Toxic and cleaning supplies are locked in the maintenance room and is inaccessible to residents in care. LPA observed fire extinguishers, fire detectors, and carbon monoxide present at the facility. LPA observed food supplies of non-perishable for a minimum of one week and perishable foods for a minimum of two days. LPA observed medications were locked in medication carts and inaccessible to residents in care. Licensing posters are posted as required. Facility is compliant with fire drills per regulations.

LPA reviewed a total of 5 residents' files and 4 staff files. All 5 residents' files contain signed Admission Agreements, Identification Sheet, Releases, Preplacement Appraisals, and Resident's Rights and updated annual medical assessment. Staff have record of all required training , First Aid and CPR, and other various care provision including required training in medications. Medications were reviewed for 5 residents. Medications are centrally stored, locked, and appear to be given per doctor's order.

LPA requested to submit documents for review and records keeping by 04/30/23.
  • Updated LIC500
  • Copy of liability insurance
There were no deficiencies found in today's inspection.
Exit interview conducted and copy of this report has provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023
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