392701540-7-10-2025-27-AS-LRIS-DJGMHN-20250711093748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701540
Report Date: 07/08/2025
Date Signed: 07/10/2025 02:01:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/15/2025 and conducted by Evaluator Arielle Pascua

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250515142650

FACILITY NAME:	LIVING GRACE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392701540
ADMINISTRATOR:	BREMER, MARLENE		FACILITY TYPE:	740
ADDRESS:	1960 WEST LOWELL AVENUE		TELEPHONE:	(559) 313-8062
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	88	CENSUS: 63	DATE:	07/08/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Farial Shokoor		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff does not ensure to follow doctor's prescription orders.
Staff do not ensure outside patio is clean and free of debris.

INVESTIGATION FINDINGS:

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On 07/08/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to deliver complaint findings. LPA met with Facility Designated Administrator (FDA), Farial Shokoor and explained the purpose of this visit. The purpose of this visit was to deliver complaint findings.

Current census was 63. A brief interview with FDA Shokoor was conducted.
During the course of this visit, LPA reviewed facility records, observations and conducted interviews.

Allegation: Staff does not ensure to follow doctor's prescription orders
It was alleged that staff does not ensure to follow doctor's prescription orders. During the course of this LPA reviewed facility records and conducted interviews. Based on interviews conducted, it was determined that Resident 1 (R1) has a prescription for a laxative to be administered every Monday, Wednesday, and Friday morning at a dosage of 17 mg for constipation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250515142650

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/08/2025

NARRATIVE

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All staff members denied that the medication was not administered according to the physician’s order. The prescription specifies that 17 mg of the medication must be mixed with 4 to 8 ounces of water prior to administration. The Licensing Program Analyst (LPA) discussed and observed the process of how the medication is to be administered. During the observation, staff demonstrated that the medication is measured up to the 17 mg line on the cap and then mixed with water as instructed. A review of R1’s Medication Administration Record (MAR) confirmed that the laxative was administered as prescribed. Additionally, bowel movement logs showed that R1 experienced regular daily bowel movements. In a follow-up interview, facility management acknowledged that medication technicians were not using a full capful but confirmed that the dosage provided still met the prescribed 17 mg. Based on the information gathered, there is not sufficient evidence to prove that staff did not provide medication as directed.

Allegation: Staff do not ensure outside patio is clean and free of debris.
It was alleged that staff do not ensure outside patio is clean and free of debris. During the course of this investigation, LPA conducted observations of the outdoor patios on 04/22/2025 and 05/22/2025. During the visit conducted on 04/22/2025, LPA Pascua observed the patio adjacent to the main dining room in the main building was found to be littered with tree debris, including pine needle-like droppings and small, circular fruits approximately half an inch in diameter. However, on 05/22/2025 and 06/13/2025, subsequent visit was conducted by the LPA who observed that the patio areas were free of debris. Based on the information gathered, there is not sufficient evidence to prove that the staff did not ensure the outside patio was clean and free of debris.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time.
An exit interview was conducted and a copy of this report and appeals rights were provided to the facility at the end of this visit.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC9099 (FAS) - (06/04)

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