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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701132
Report Date: 08/18/2022
Date Signed: 08/18/2022 03:03:25 PM


Document Has Been Signed on 08/18/2022 03:03 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:GRACEFUL LIVING AT VILLAGE ONEFACILITY NUMBER:
502701132
ADMINISTRATOR:SUASIN, LETECIAFACILITY TYPE:
740
ADDRESS:3128 AMOS CTTELEPHONE:
(209) 595-1028
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 5DATE:
08/18/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee, Voica Matis TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Sarah Hurt arrived to conduct an unannounced Post Licensing inspection on this date and met with Licensee Voica Matis. There are currently 5 residents currently living at the facility.

LPA inspected the physical plant with including the kitchen, bedrooms. bathrooms; living areas, and backyard area. LPA observed the facility in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed the rooms to be clean and organized with comfortable furnishings. .

LPA observed the following posted in the entrance of the facility:, Resident Personal Rights, Evacuation Routes and facility license were all posted as required. See Something Say Something complaint poster is posted.

LPA confirmed all residents files have required records.

No deficiencies Per Title 22 Regulations were observed on this visit.

Exit interview held with Licensee Voica Matis and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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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