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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701059
Report Date: 07/15/2022
Date Signed: 07/15/2022 01:51:46 PM


Document Has Been Signed on 07/15/2022 01:51 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
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) 329-8745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
07/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Patricia MatiasTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 7/15/22 at 10:15am. Administrator Certificate expires 1/30/2023.

LPA met with Patricia Matias, Administrator and discussed the purpose of the visit. The facility is licensed for a capacity of 6 residents. There are 3 residents present at this time. LPA observed 2-day perishables and 7-day non-perishables. There is a hospice waiver for 2 but 0 are receiving the services at this time. The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 108.3*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

-LPA inquired about discoloration on refrigerator. Administrator stated that it is oxidation and the ice doesn't work for resident use.
-LPA observed the LIC 500 that does not include the complete date of employment and does not indicate 24/7 coverage according to Department of labor laws.
-LPA observed resident records to be incomplete either by staff and/or physician dates and signature are needed as well.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308) in accordance to Title 22 regulations
Personnel Report (LIC500) with complete dates
LIC308 and LIC500 to indicate 24/7 coverage following the Dept of Labor laws
Administrator Certificate-Updated

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, in lieu of citations the facility received a Technical Violation (LIC9102) which is allowing time to correct the above mentioned items within a 30 day time span. Exit interview held, copy of report given
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
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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