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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701361
Report Date: 08/28/2024
Date Signed: 08/28/2024 09:46:23 PM


Document Has Been Signed on 08/28/2024 09:46 PM - 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:GRACEFUL LIVING FOR SENIORSFACILITY NUMBER:
392701361
ADMINISTRATOR:WHITNEY, JENNIFERFACILITY TYPE:
740
ADDRESS:1661 WILLOW PARK WAYTELEPHONE:
(209) 808-8140
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:5CENSUS: 0DATE:
08/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Applicant, Kathleen Quiaot. TIME COMPLETED:
12:30 PM
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Announced prelicensing visit was made by LPA Lund. LPA Lund met with applicant, Kathleen Quiaot. and explained the reason for the visit. Census: 0

The facility will be licensed to serve up to (5) residents for Valley Mountain Regional Center at any given time. This Applicant is seeking a facility with five non-ambulatory residents. LPA Lund and applicant, Kathleen Quiaot tour/inspected the facility. LPA inspected the dining area, living area, and all other areas intended for resident use. LPA observed to be furnished and maintained in compliance at this time. The Facility had a Medication cabinet (locked) where medication will be stored. First aid kit was observed in the Medication cabinet to be present and contained all required components at this time. A tour of the (3) resident bedrooms and one room for staff, was conducted all four rooms in which two can share. Furnishings intended for use by the residents were observed to meet the needs of the residents at this time. The facility also had two bathrooms for the residents.

A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. The facility has one (1/16/2024) fire extinguishers that and carbon monoxide are in compliance. The has a working telephone.

This facility has been found to be in compliance at this time.
applicant, Kathleen Quiaot completed the Component 111 requirements. Exit interview and report left.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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