<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700414
Report Date: 11/09/2020
Date Signed: 11/09/2020 12:16:53 PM

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:CHIANTI GRACE LLCFACILITY NUMBER:
392700414
ADMINISTRATOR:NANQUIL, MARY ANNFACILITY TYPE:
740
ADDRESS:9063 CHIANTI CIRTELEPHONE:
(209) 451-4528
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 5DATE:
11/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mary LaurelTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA's) Albert Johnson and Ashley Boothe conducted a health and safety check on this day.

At 9:15 LPA's and administrator toured the facility and observed the following deficiencies in the facility: unlocked toxic chemicals underneath the bathroom and kitchen sinks, unlocked medications and writing on the labels and medications without prescriptions, expired and unlabeled food stored, smoke detector removed and placed on the kitchen counter, cloth towels hanging in restroom, bed rails on Resident 1 (R1)'s bed, a broken and leaning patio umbrella in the backyard patio table, Staff one (S1) did not wear a face covering while providing care and supervision to residents in care in violation of official government orders requiring the wearing of face coverings while working under specified conditions, and S1 did not screen LPA's per COVID precautionary guidelines.

During file review at 10:45, LPA's and administrator observed records for R1 and R2 and S1 including doctors orders not on file for home health services for R1, Bed rails on R1's bed not documented in R1's LIC602, R1's LIC602 states non ambulatory but R1 stated during interview she can not and has not been able to move out of her bed since R1 moved into the facility.

Deficiencies were given pursuant to Title 22 rules and regulations, Health and Safety Codes. An exit interview was conducted with Mary. A a copy of this report was provided to Mary via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Mary is print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
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 4
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: CHIANTI GRACE LLC
FACILITY NUMBER: 392700414
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2020
Section Cited

1
2
3
4
5
6
7
87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (b) Medicines which are centrally stored shall be stored as specified in Section 87465 and separately from other items specified in (a) above.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
LPA's and administrator observed that toxins and cleaning supplies to be unlocked in the cabinets underneath the kitchen and bathroom sinks which poses an immediate risk to residents in care.
8
9
10
11
12
13
14
Type A
11/10/2020
Section Cited

1
2
3
4
5
6
7
Fire Clearance 87202(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
LPA's and administrator observed a smoke detector removed and placed on the kitchen counter, administrator states it goes off while cooking meals, which poses an immediate risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: CHIANTI GRACE LLC
FACILITY NUMBER: 392700414
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2020
Section Cited

1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities(a)) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: LPA's and adminstrator observed cloth towels in the restrooms. LPA's observed Staff one (S1) did not wear a face covering while providing care and supervision to residents in care in violation of official government orders requiring the wearing of face coverings while working under specified conditions, and S1 did not screen LPA's per COVID precautionary guidelines which poses an immediate risk to residents in care.
8
9
10
11
12
13
14
Type B
11/18/2020
Section Cited

1
2
3
4
5
6
7
87608 Postural Supports (a) Based on the individual's...appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: LPA's and adminstrator's interview and observation of records R1's has bed rails and there are no doctor's orders on file.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: CHIANTI GRACE LLC
FACILITY NUMBER: 392700414
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2020
Section Cited

1
2
3
4
5
6
7
Resident records (a The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff (10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: LPA's and adminstrator's observation and interview of R1 and R1's resident records for home health services. R1 needs doctor's orders for reasons for home health services and the use of bed rails.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4