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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700547
Report Date: 03/08/2023
Date Signed: 03/08/2023 12:15:38 PM


Document Has Been Signed on 03/08/2023 12:15 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:AMAZING GRACE ELDER CARE LLCFACILITY NUMBER:
342700547
ADMINISTRATOR:STERLING, GRACE KELLYNFACILITY TYPE:
740
ADDRESS:6015 TUPELO DRIVETELEPHONE:
(916) 801-4386
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 6DATE:
03/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator: Grace Kellyn Sterling TIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 03/08/2022 to conduct a Required-1 Year Inspection utilizing the care inspection tool . LPA met with Administrator, Grace Kellyn Sterling, 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. LPA observed two (2) staff and three (3) residents at the facility.

LPA toured the facility to ensure the health and safety of the residents in care. Areas toured include but are not limited to: 5 bedrooms and 2 bathrooms for residents, common areas, dining room, food supply, laundry room, and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed. First aid supplies completed and emergency lighting available. The facility was free of odor, clean, and in good repair at time of inspection. Resident bedrooms were found to be free of odor, clean and in good repair. Bathrooms were clean and in good repair, equipped with required grab bars and non-skid mats. Fire extinguisher was observed to be fully charged and last serviced on 05/09/2022. Knives, cleaning supplies, and centrally stored medication were observed to be locked and inaccessible to residents. Food supply was adequate for 2-day perishable and 7-day nonperishable.

LPA reviewed six (6) resident records and resident records were found to be complete and current. Two (2) staff records were reviewed and records were found to be complete and current. Staff training records were reviewed and were found to be completed and current. Both staff completed first aid training and received certificates.

No deficiencies are being cited.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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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