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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700941
Report Date: 12/15/2021
Date Signed: 12/16/2021 04:31:29 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:
392700941
ADMINISTRATOR:LAUREL, MARICARFACILITY TYPE:
740
ADDRESS:9063 CHIANTI CIRCLETELEPHONE:
(209) 688-8058
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 6DATE:
12/15/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Maricar Laurel, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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On 12/15/2021 LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Administrator, Maricar Laurel and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 residents, which 4 may be non-ambulatory and 1 on hospice.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents.nThere is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.
Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on July 09, 2021. First aid kit was observed to be complete. Fire drill was last conducted on 11/08/2021. LPA observed completed mitigation plan. LPA reviewed 4 resident files and 2 staff files.

- LPA observed hot water in the shared resident's bathrooms measured at 153 and 140 degrees F.
- LPA observed 2 pair of scissors in the unlocked kitchen cabinet accessible to dementia residents in care.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with Administrator. A copy of report and Appeal Rights given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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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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: 392700941
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 87303(e)(2). LPA observed hot water temperature in residents shared bathroom measured at 140 and 153 degree F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2021
Plan of Correction
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Administrator adjusted hot water temperature and LPA observed hot water temperature measured at 117 degrees F. Deficiency cleared during inspection.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 87705(f). LPA observed 2 pairs of scissors accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2021
Plan of Correction
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Administrator removed scissors and locked it away. Deficiency cleared during inspection.
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: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021
LIC809 (FAS) - (06/04)
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