392701540-4-23-2026-27-AS-CYAG-DTELPT-20260423085627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701540
Report Date: 04/17/2026
Date Signed: 04/23/2026 08:56:51 AM

Document Has Been Signed on 04/23/2026 08:56 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:	LIVING GRACE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392701540
ADMINISTRATOR/ DIRECTOR:	MARLENE BREMER		FACILITY TYPE:	740
ADDRESS:	1960 WEST LOWELL AVENUE		TELEPHONE:	(209) 833-2200
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY: 88		CENSUS: 68	DATE:	04/17/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Farial Shokoor		TIME VISIT/ INSPECTION COMPLETED:	02:00 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	Unannounced annual visit made out to this facility on 04/17/2026 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Farial Shokoor, who was briefly interviewed at this time. It was learned that there were (14) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (25) residents at any given time. It was learned that there were residents diagnosed with dementia at this time. This facility does have an approved program to be able to accept and retain residents diagnosed with dementia at any given time. This facility does have a memory care unit on site at this time. Current census was 68 residents for all three components of this facility at this time. Tour of the facility was conducted. A tour of the facility kitchen area was conducted. Food storage units, refrigerators and freezers, were toured. It was observed that there was a sufficient supply of 2-day perishable food quantities available on site to meet the requirements at this time. Pantry area was toured. It was observed that there was a sufficient supply of 7-day nonperishable food quantities available on site to meet the requirements at this time. A sample review was conducted for the facility resident bedrooms at this time. It was observed that furniture and furnishings were observed to be functional and maintained in compliance at this time. A sample review was conducted for the facility resident restrooms at this time. Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times. Grab bars and non skid surfaces were observed to be present and maintained in compliance at this time. Living areas, dining areas, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LIVING GRACE ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 392701540
	VISIT DATE: 04/17/2026

NARRATIVE

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Laundry room was toured. It was observed to be locked and all laundry detergents, bleach, and supplies were made inaccessible to the residents at this time.
Rooms designated as supply rooms, storage rooms, and equipment rooms were observed to be locked and made inaccessible to the residents at this time.
Medication carts were reviewed alongside the facility designated Administrator and present medication technician. Policies and procedures in regards to the handling, dispensing, and documentation of the resident medications were discussed at this time. This facility utilized mobile medication carts that were pushed out into the facility when it was time to dispense the medications to the residents.
It was learned that this facility employed an E-MAR system as well as documented paperwork for the facility resident medications at this time.
First aid kit, located in the medication carts, was observed to contain all of the required components at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Annual Fire and Safety, on 02/18/2026 and found to be in compliance at this time.
A tour of the facility exterior grounds was conducted. A review of the perimeter fence, side gates, and all other exits was conducted at this time.

A review of (6) facility resident files was conducted and noted on the following LIC 858.
A review of (6) facility personnel files was conducted and noted on the following LIC 859.
The following forms and documents were requested by this LPA to be updated and submitted into CCL:
LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/23/2026 08:56 AM - It Cannot Be Edited

Created By: Charlie Yang On 04/17/2026 at 02:21 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LIVING GRACE ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 392701540
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(c)

Personnel Records

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that [2] out of [6] facility personnel files did not contain updated annual training topics and hours which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2026
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that an audit of all personnel files will be conducted to make sure that facility staff providing care and supervision to the residents in care are properly updated with the necessary training topics and obtain the required number of hours. A statement of correction, along with updated proof of training, will be completed and submitted into CCL for review by this LPA by the due date.

Type A

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that [2] out of [6] facility personnel files did not have updated First Aid training which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2026
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that an audit of all personnel files will be conducted to make sure that facility staff providing care and supervision to the residents in care are properly updated with the necessary training for First Aid. A statement of correction, along with updated proof of training, will be completed and submitted into CCL for review by this LPA by the due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

	Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

LIC809 (FAS) - (06/04)

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