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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700317
Report Date: 06/20/2024
Date Signed: 06/20/2024 10:47:53 AM


Document Has Been Signed on 06/20/2024 10:47 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:
06/20/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Nelson JacintoTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 06/20/24 to do case management visit. LPA met with Administrator, Nelson Jacinto and explained the purpose of the visit.

During complaint investigation (59-AS-20240613135559), while doing facility tour, LPA observed multiple food items in the kitchen area ( in pantry room ) which poses a potential health and safety risks to residents in care.

Immediate Civil penalties of $250.00 were assessed on LIC421FC today due to repeat violations of the same regulations within 12 months for Regulation 87555.

Deficiencies issued are noted on the LIC809D per Title 22 Regulations.

Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted. Appeal rights were provided and copy of the report was provided.









SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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 06/20/2024 10:47 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: 06/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2024
Section Cited
CCR
87555(b)(8)

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87555-(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained....This requirement is not met as evidenced by:
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Administrator shall submit a letter of understanding and shall do staff training regarding this regulation and ensure that facility shall not any expired food items and food shall be labeled and dated per requiement. All POC documents are due by 06/27/24.
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During visit, LPA observed food supply with multiple expired items, and food items without date or label, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Immediate Civil penalties of $250.00 were assessed on LIC421FC today due to repeat violations of the same regulations within 12 months for Regulation 87555.

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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: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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