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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700547
Report Date: 03/13/2024
Date Signed: 03/13/2024 03:26:41 PM


Document Has Been Signed on 03/13/2024 03:26 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: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: 5DATE:
03/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator- Grace SterlingTIME COMPLETED:
03:35 PM
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On 03/13/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a 1 year required annual inspection utilizing the Care tool. LPA met with Caregiver, April Peracchi and explained the purpose of the visit. Caregiver notified administrator of LPA presences at the facility. Administrator, Grace Sterling later arrived at the facility.

LPA and Administrator toured the interior and exterior of the facility. Areas toured include but are not limited to: five (5) bedrooms, two (2) bathrooms, common areas, dining room, kitchen, and outdoor area. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins, cleaning supplies, knives and medications are locked and inaccessible to residents in care. Hot water temperature was measured at 116.8 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 74 degrees. First aid kit was completed. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed the fire extinguisher, located near entry way, which was lasted inspected on 01/24/24. LPA observed required Licensing posters posted throughout the facility.

LPA conducted a file review of two (2) personnel and five (5) residents records. All records have the required documents.

No deficiencies are being cited during today's inspection.

Exit interview conducted and a copy of the repeat was left at the facility.


SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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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