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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701059
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:29:47 PM


Document Has Been Signed on 07/06/2023 03:29 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: 5DATE:
07/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:28 PM
MET WITH:Patricia MatiasTIME COMPLETED:
02:29 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 7/6/23 at 2:20pm. Administrator Certificate expired 1/30/2023, however, the pertinent documents and fees were submitted to Community Care Licensing and the updated certificate has not been received yet. License fees are current.

LPA met with Patricia Matias, Administrator and discussed the purpose of the visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which 1 maybe bedridden in room #3 only. 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 108.8 *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.

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, no deficiencies cited during this visit. 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: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
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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