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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700941
Report Date: 01/10/2022
Date Signed: 01/10/2022 03:54:39 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: 5DATE:
01/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Maricar Laurel, Facility AdministratorTIME COMPLETED:
10:30 AM
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LPA Bruce Jacobs arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by care staff who informed Administrator Maricar Laurel the LPA's visit and Maricar arrived during the visit. LPA explained the purpose of the visit and Ms. Laurel and staff accompanied LPA on the facility inspection.

LPA Jacobs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 5 and no residents are currently on hospice. There are 4 client bedrooms and 2 client bathrooms. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing and other signage noted. Medications noted to be locked to residents in care. .LPA also conducted the infection control domain tool.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
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
VISIT DATE: 01/10/2022
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The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher is in compliance and were serviced in July 2021.. Facility has an emergency food and water supply in a separate storage area in kitchen. All care staff on-site had current fingerprint clearances. Water temperature was measure at 117.5 F.

LPA requested the following documents to be updated: LIC 500 and LIC 309 as needed.

Per California Code of Regulations, no Title 22 deficiencies were observed during this visit. Exit interview was held and a report was provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
LIC809 (FAS) - (06/04)
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