502701132-2-11-2022-27-AS-SHUT-CBJM2Q-20220211081352

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701132
Report Date: 02/10/2022
Date Signed: 02/11/2022 08:13:59 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GRACEFUL LIVING AT VILLAGE ONE		FACILITY NUMBER:	502701132
ADMINISTRATOR:	MATIS, VOICA		FACILITY TYPE:	740
ADDRESS:	3128 AMOS CT		TELEPHONE:	(209) 595-1028
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	6	CENSUS:	DATE:	02/10/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee, Voica Matis		TIME COMPLETED:	11:45 PM

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Licensing Program Analyst (LPA) Sarah Hurt conducted an announced visit on to the facility on 02/10/2022 at 9 a.m. for purpose of a Pre-Licensing evaluation. LPA arrived and was granted entry to the facility by Applicant Voica Matis An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Unit (CAU) on 11/30/2021 for a capacity of six non-ambulatory residents.

LPA Hurt observed the following:
Structure:
Facility is a one story house with 4 resident bedrooms, 2 bathrooms, family / living room, dining area and kitchen. There is a 3 car garage attached in front of home. The resident bedrooms will accommodate residents' furnishings.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Residents:
Bedrooms #1-4 will accommodate 6 non-ambulatory residents
Bathrooms:
All bathrooms have a working toilet, wash basin, and walk-in/shower.
Linens and Hygiene Supplies:
Adequate supply of linens is stored in hallway closet.
Emergency Phone Numbers, Exit Plan, and Sample Menu:
Will be posted and readily available for review in the living room.

Continued on 809C...

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE	FACILITY NUMBER: 502701132
	VISIT DATE: 02/10/2022

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Continued from 809..

Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables would be stored in the kitchen and pantry.
Smoke and Carbon Monoxide Detectors:
Smoke and carbon monoxide alert systems were hardwired and found operational.
Fire Extinguisher:
2 Fully charged and stored by the kitchen and in the garage.
Fire Clearance:
Approved on 01/19/2022
Appliances:
Gas four burner stove with oven, refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer are located in the laundry room next to kitchen and were clean and noted to be operational.
Toxins:
Will be locked and stored under kitchen sink.
Water Temperature:
Tested and recorded at 118 degrees (within regulation)
Medications, First Aid Kit & Manual:
First Aid kit with guide will be stored next to kitchen. Medication will be stored and locked in kitchen.
Resident and Staff Files:
Records will be kept in medication cabinet.
Reading Material, Games, Equipment, & Materials:
The facility has materials that commensurate with their plan of operation.

Continued on 809C.. .

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE	FACILITY NUMBER: 502701132
	VISIT DATE: 02/10/2022

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LPA will contact Central Applications Bureau (CAB) to advised the applicant has passed the Pre-Licensing portion of the application process.

Applicant was reminded of the statute that requires notification to Licensing Program Analyst within 5 business days of admitting the first resident. This notification may be done by phone, mail, email or fax.

An exit interview was conducted with Voica Matis, and a copy of this report was provided at the time of visit.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC809 (FAS) - (06/04)

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