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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700317
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:33:44 PM


Document Has Been Signed on 10/26/2023 03:33 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:
10/26/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Nelson JacintoTIME COMPLETED:
03:45 PM
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On 10/26/23, Licensing Program Analyst (LPA) Talwinder Bains arrived to conduct a case management and perform a health and safety check on residents in care. LPA met with administrator Nelson Jacinto and explained the purpose of todays' visit.

LPA toured the facility with Administrator to check the health and safety of residents in care. Areas toured included but not limited to residents rooms, bathrooms, common areas and outside area. LPA toured kitchen area and observed that facility has adequate food supply of 2 days perishable and 7 days non perishable per regulation. LPA observed some residents were outside area and some were in their rooms. LPA observed that facility was clean and odor free. LPA observed that staff were attentive to residents care needs during tour. From the tour, there was no immediate health and safety risks observed for the residents in care.

LPA and administrator discussed recent visit for resident, R1 to hospital (10/24/23 to 10/26/23) regarding R1s hip pain which was related to R1s hip surgery which was conducted in Sep. 2023 and R1 still experience lot of pain in their hip. Interview and record review indicated that R1 has been prescribed new pain medication and therapy upon discharge on 10/26/23 to address hip pain. LPA and administrator discussed the plan of relocating one of current resident, R2 to another facility since R2 was constant exit seeker and facility was working with R2s social worker to find another facility.



LPA interviewed 3 residents and 3 staff during today's visit and concluded no immediate health or safety concerns for residents as of today.

As a result of today’s visit, no deficiencies were observed or cited.
The report was reviewed, and a copy 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: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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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