502700004-12-1-2023-27-AS-MJEN-CY4LKJ-20231201074938

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700004
Report Date: 11/07/2023
Date Signed: 12/01/2023 07:50:05 AM

Document Has Been Signed on 12/01/2023 07:50 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:	GRACEFUL LIVING AT OAKDALE 3		FACILITY NUMBER:	502700004
ADMINISTRATOR:	MATIS, VOICA		FACILITY TYPE:	740
ADDRESS:	537 FRESIAN DRIVE		TELEPHONE:	(209) 595-1028
CITY:	OAKDALE	STATE: CA	ZIP CODE:	95361
CAPACITY:	6	CENSUS: 5	DATE:	11/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Rainilda Clavano		TIME COMPLETED:	05:15 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	On 11/7/23 at approximately 2:20 pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with care coordinator Rainilda Clavano and explained the purpose of today's visit. The Licensee, Voica Matis, holds a current Administrator certificate good through 12/16/2023. The annual fees were verified to be current. LPA Jensen toured the grounds and determined all paths to be free of obstruction. The grounds were observed to be maintained. There is outdoor seating available with shaded areas for client engagement. All screens were in good repair. LPA Jensen toured the interior. The facility was observed to sanitary and was free of odor. There was adequate lighting and furniture throughout. There are night lights available in the hallway. The facility maintains adequate linens and hygiene supplies. All appliances are in good working order. LPA Jensen toured the kitchen and observed in excess of a two day supply of perishable food and a 7 day supply of non-perishable food. There was a variety of fresh fruit and vegetables available. LPA Jensen observed the meal service preparation for dinner which consisted of lasagna, broccoli, and ice cream. LPA Jensen observed a refrigerator in the garage where temperature sensitive medications were stored. The access door to the garage was not locked and morphine was stored in the garage refrigerator. Based on interviews with staff, the door is usually locked and residents do not generally go in the garage. All toxins and sharp objects were locked and inaccessible. The fire extinguisher and carbon monoxide detector were observed to be in compliance. The first aid kit was observed to be complete and in compliance. Regular fire drills are conducted. The facility maintains and an adequate supply of emergency food. The emergency disaster plan has recently been updated and is in compliance.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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

FACILITY NAME: GRACEFUL LIVING AT OAKDALE 3	FACILITY NUMBER: 502700004
	VISIT DATE: 11/07/2023

NARRATIVE

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LPA Jensen reviewed 5 of 5 resident files and determined them to be complete. LPA Jensen reviewed 2 staff files and determined them to be complete. LPA Jensen requested and received a current copy of the liability insurance and an LIC 500. All staff present were observed to have criminal back ground clearance and were associated to the facility. LPA Jensen observed residents engaged in various activities including singing and visiting with family members.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/01/2023 07:50 AM - It Cannot Be Edited

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: GRACEFUL LIVING AT OAKDALE 3	FACILITY NUMBER: 502700004
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(2)

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensen's observation of morphine in a refrigerator in an unlocked garage, the licensee did not comply with the section cited above in 1 count which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2023
	Plan of Correction
1 2 3 4	The Licensee placed the medication in a locked storage box and counseled staff in the presence of the LPA. No further action required.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Rios	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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