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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701059
Report Date: 07/12/2021
Date Signed: 07/12/2021 10:43:34 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:AMAZING GRACE ELDER CARE #2FACILITY NUMBER:
342701059
ADMINISTRATOR:MATIAS, PATRICIAFACILITY TYPE:
740
ADDRESS:7723 EL RITO WAYTELEPHONE:
(916) 801-4386
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 5DATE:
07/12/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Patricia Matias and Nathaniel SterlingTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 07/12/2021 at 9:15 AM to conduct a pre-licensing inspection. LPA met with Administrator Patricia Matias and explained the purpose of the visit. LPA was allowed entry into the home that will be licensed for a capacity of 6 non-ambulatory residents. Licensee Nathaniel Sterling arrived at the facility at 10:00 AM.

Administrator holds current certificate # 6024213740 and expires on 1/30/2023. LPA toured and inspected the physical plant inside and outside with the administrator Patricia Matias to ensure there are no health and safety concerns on 07/12/2021 at 9:30 AM. LPA observed there are 5 residents at this time.

The facility has Covid-19 posting throughout the facility. The facility has submitted a mitigation plan to CCLD, and it was approved on 7/6/2021. The facility has one central entry point, and the facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented.

LPA observed the kitchen area, dining area, (6) bedrooms, (2) bathrooms, storage areas, and laundry rooms. LPA observed required furniture, and lighting throughout the facility. Facility bathrooms are sanitary. Facility bedrooms are furnished and sanitary. The hot water temperature was measured at 108.5 degrees Fahrenheit during this visit. Facility shall maintain the hot water temperature within the required range of 105-120*F. The temperature inside the facility measured at 70*F which is within the required range of 68-85*F.


Continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: AMAZING GRACE ELDER CARE #2
FACILITY NUMBER: 342701059
VISIT DATE: 07/12/2021
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LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed knives/sharps area to be locked. LPA observed centrally stored medications area to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the home were in good repair. LPA observed the area where the staff and resident files are locked and readily available for review. The facility first aid kit is up to date.

Component III was waived - Licensure pending. The applicant has passed the pre-licensing component of the application process. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC809 (FAS) - (06/04)
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