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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701059
Report Date: 07/19/2024
Date Signed: 07/19/2024 10:57:52 AM

Document Has Been Signed on 07/19/2024 10:57 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/
DIRECTOR:		MATIAS, PATRICIAFACILITY TYPE:
740
ADDRESS:7723 EL RITO WAYTELEPHONE:
(916) 329-8745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Patricia MatiasTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 7/19/24 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at Amazing Grace Elder Care #2 for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Patricia Matias and together conducted a tour of the home.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor and clean. LPA observed the door to the staff bedroom is broken and in need of repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed there are currently two refrigerators and a freezer in the kitchen/living room; the freezer is blocking a passageway and should be moved to accommodate residents and ensure residents can safely ambulate in the kitchen. also observed a camera in the entry way with a direct view of a resident bathroom. LPA requested the camera be removed.

LPA measured the water temperature, temperature measured at 114 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. All resident and staff files were complete and well organized.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 9020 client roster and current administrator certificate.

Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
Kevin GouldTELEPHONE: (619) 672-5924
DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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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Document Has Been Signed on 07/19/2024 10:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #2
FACILITY NUMBER: 342701059

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Section Cited
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations the licensee did not comply with the section cited above as LPA observed the door to the staff bedroom to be broken and not working as designed and in need of repair which poses an immediate health, safety or personal rights risk to residents, employees and visitors.
POC Due Date: 07/20/2024
Plan of Correction
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A written plan of correction will be submitted by the POC due date indicating the steps facility will take to repair door and provide an estimated completion date for the door repair.
Deficiency Dismissed
Section Cited
Personal Accommodations and Services
(c) Individual privacy shall be provided in all toilet, bath and shower areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above as LPA observed a camera in the entryway with a unobstructed view to a resident bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2024
Plan of Correction
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Licensee will remove camera and provide a written statement acknowledging that no cameras will be placed with a direct view of a resident bedroom or bathroom.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
Kevin GouldTELEPHONE: (619) 672-5924

DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/19/2024 10:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #2
FACILITY NUMBER: 342701059

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Section Cited
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations the licensee did not comply with the section cited above as there is a freezer in the kitchen that obstructs the passageway in the kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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Freezer will be moved to an area of the home that does not obstruct resident movement in the kitchen.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
Kevin GouldTELEPHONE: (619) 672-5924

DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024

LIC809 (FAS) - (06/04)
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