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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700004
Report Date: 11/25/2024
Date Signed: 11/25/2024 12:35:11 PM

Document Has Been Signed on 11/25/2024 12:35 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 AT OAKDALE 3FACILITY NUMBER:
502700004
ADMINISTRATOR/
DIRECTOR:		MATIS, VOICAFACILITY TYPE:
740
ADDRESS:537 FRESIAN DRIVETELEPHONE:
(209) 595-1028
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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On 11/25/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Administrator Voica Matis and explained the purpose of today's visit.

LPA Jensen toured the grounds which were observed to be well maintained. All paths were free of obstruction. The window screens were in good repair. There is a shaded area and patio furniture for clients to enjoy outdoor activities. The back gate has a self closing latch. LPA Jensen toured the interior and observed the facility to be sanitary and free of odor. There was adequate lighting and furnishings throughout. LPA Jensen inspected the kitchen and observed 2 days of perishable food and 7 days of non-perishable food to be available. There was fresh fruit including apples, bananas, pears and oranges as well as a variety of fresh vegetables. LPA Jensen observed lunch service which consisted of BLT sandwich, fries, juice and ice cream for dessert.

LPA Jensen inspected the common areas, bedrooms, laundry room, bathrooms and garage. The water temperature in the bathroom was tested and determined to be within the required range. There are adequate linens available for frequent bedding changes. The fire extinguisher was last serviced in April of 2024 and is in compliance. The carbon monoxide detector was tested and found to be in good working order. The facility maintains first aid kits that are complete. All medications were observed to be locked and inaccessible to residents in care.

LPA Jensen reviewed 3 of 3 resident files and both staff files for the care providers that were present on this day. The resident files and staff files were complete and in compliance. The facility has capacity for 6 residents, all of which can be non-ambulatory. There is also a hospice waiver for 2. Currently there are 2 non-ambulatory residents and 1 resident on hospice.
Lisa RiosTELEPHONE: (916) 969-9685
Maja JensenTELEPHONE: (916) 639-5584
DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 11/25/2024
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The staff present on this day were verified as having criminal background clearance. The facility has a van for transporting residents to appointments if needed. LPA Jensen verified the van has current registration and liability insurance. LPA Jensen and Administrator Voica Matis discussed updates to dementia care that take effect on January 1, 2025.

The facility was determined to be in substantial compliance. No deficiencies were observed. An exit interview was conducted and a copy of this report was given.


SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC809 (FAS) - (06/04)
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