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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701059
Report Date: 07/25/2024
Date Signed: 07/25/2024 09:23:57 AM


Document Has Been Signed on 07/25/2024 09:23 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
07/25/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Wendy NogueraTIME COMPLETED:
10:15 AM
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On 7/25/24 at 9:00am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced POC inspection to ensure previous deficiencies have been corrected.

LPA conducted a walk through of the home and observed the refrigerator moved to create a open walking space in the kitchen. Staff bedroom door has been repaired and is working as designed. LPA also observed the camera in the front entry way has been relocated and no longer poses a potential personal rights risk to residents in care. All deficiencies have been cleared and a POC clearance letter was provided to the facility.

Exit interview conducted and a copy of this report was left at the home.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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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