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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700317
Report Date: 04/20/2023
Date Signed: 04/20/2023 12:01:34 PM


Document Has Been Signed on 04/20/2023 12:01 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Nelson Jacinto TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 04/20/2023 to conduct a case management inspection to follow up on a recent AWOL at the facility. LPA met with Nelson Jacinto, Administrator and explained the purpose of the visit. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical mask.

The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 03/24/23 regarding resident (R1) leaving the facility unattended on 03/23/23, at approximately 07.30am. On 03/23/23 around 08.10am, facility filed missing person complaint for R1 and notified R1s conservator. Around 11.00am, Facility was notified by R1s conservator that R1 was dropped off at local Walmart. Facility staff followed up immediately after this call and found R1 at local Walmart. Resident was brought back to the facility uninjured. Facility notified R1 doctor and family on 03/24/23 regarding this AWOL incident.

R1's physician's report, indicates that resident has primary diagnosis of neurocognitive disorder with secondary diagnosis of schizophrenia and cannot leave the facility unassisted. This was first AWOL incident for R1 since R1s admission to the facility. Resident has not tried to leave facility again and has been communicating better with the staff if R1 needs something.

No deficiencies were cited during today's visit.
Exit interview conducted and copy of the report left at the facility.




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)
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