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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701132
Report Date: 03/27/2023
Date Signed: 04/24/2023 09:29:15 AM


Document Has Been Signed on 04/24/2023 09:29 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 AC/SC, 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:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Vocia MatisTIME COMPLETED:
02:30 PM
NARRATIVE
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On 0/3/27/23, at 10:00 AM, an unannounced annual inspection was conducted by Licensing Program Analysts, (LPAs), Kimberly Viarella and Charlie Yang at Graceful Living at Village One in Modesto. LPAs identified themselves and the purpose of their visit to staff, Rainilda Clavano, and instructed that the facility administrator be notified of their arrival.

Voica Matis, Licensee, arrived and stated that Letecia Suasin, the listed designated facility administrator, was on vacation and that she was the designated facility administrator. A brief interview with the designated facility administrator followed. Facility reported census was 5 with 2 bedridden and 2 hospice, no home health at this time. Upon inspection the LPA noted a census of 5 of which 3 were bedridden based on the LIC 602 and 3 were receiving hospice services. The facility is licensed for 6 nonambulatory and 1 bedridden and has been approved for a hospice waiver for 2 residents. Residents with dementia were observed to be in care at this facility.

The tour began in the kitchen/areas. LPAs checked the food supply and found that there were enough groceries for 2 days of perishable and 7 days of non-perishable items at this time. Knives were secured in a locked drawer and chemicals were stored in a locked cabinet under the sink and separate from the food supply. The fire extinguisher was last inspected on 03/06/2023, by Stanislaus Fire.

The tour progressed to the backyard. An alert sounded upon exiting the building. There were no bodies of water present. LPAs observed a wooden fence enclosing the backyard.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
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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Document Has Been Signed on 04/24/2023 09:29 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE
FACILITY NUMBER: 502701132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above in 1 out of 1 insatnces when they failed to obtain a building permit and notify licensing of coverting a section of the garage into a staff room. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
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Licensee will obtain a building permit and update the faciltiy sketch. These items will be submitted to CCL via email kimberly.viarella@dss.ca.gov by 04/11/2023.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review 4 staff files, the licensee did not comply with the section cited above in 3 of 4 staff files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
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The licensee will ensure that a # staff be First Aid /CPR certified by 04/11/2023. These items will be submitted to CCL via email kimberly.viarella@dss.ca.gov by 04/11/2023.
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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2023 09:29 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE
FACILITY NUMBER: 502701132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 staff files did not contain a helalth screening which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2023
Plan of Correction
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The licensee will ensure that all staff identified on the LIC 500 will have a health screening and a negative TB test result and will submit these documents to CCL at kimberly.viarella@dss.ca.gov by 04/11/2023.

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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE
FACILITY NUMBER: 502701132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. 2 out of 4 staff files did not contain a proof of a negative TB test which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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The licensee will ensure that all staff identified on the LIC 500 will have a health screening and a negative TB test result and will submit these documents to CCL at kimberly.viarella@dss.ca.gov by 04/11/2023.
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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The licensee will ensure that all staff identified on the LIC 500 will have all of the training requirements completed and will submit these documents to CCL at kimberly.viarella@dss.ca.gov by 04/11/2023.
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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2023 09:29 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE
FACILITY NUMBER: 502701132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the sliding doors off of the kitchen area did not have window sceens . This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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Photos of the sliders with window screens will be submitted to CCL at kimberly.viarella@dss.ca.gov by 04/21/2023.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff files were missing personnel record /job applications. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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Licenssee will develop a tracking system to ensure that all staff files contain the required information. A copy of this tracking system will be submitted to CCL at kimberly.viarella@dss.ca.gov by 04/21/2023.
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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2023 09:29 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE
FACILITY NUMBER: 502701132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 resident files were incomplete which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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Licensee will create a tracking system and ensure that all resient files will contain the required documents going forward. This tracking system will be submitted to CCL at kimberly.viarella@dss.ca.gov by 04/21/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2023 09:29 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE
FACILITY NUMBER: 502701132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and file review, the facility failed to obtain fire clearance for the three bedridden residents witnessed during the facility inspection.
POC Due Date: 04/11/2023
Plan of Correction
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The licensee will submit an updated facilty sketch and LIC 200 to request an increase in their bedridden capactiy via fire inspection. This information shall be submitted by the end of the day, 04/11/2023 to CCL at kimberly.viarella@dss.ca.gov.
Type A
Section Cited
CCR
87355(c)


This requirement is not met as evidenced by:
Deficient Practice Statement
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87355(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility
Based on record review and observation, the licensee did not comply with the section cited above as 4 out of 5 of staff present during facility inpsection were not associated, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
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The Licensee will utilize Guardian to update and associate all staff members that will be working at this faciltiy. A copy of the facility roster will be submitted to CCL at kimberly.viarella@dss.ca.gov as proof of correction by 04/06/2023.
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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
LIC809 (FAS) - (06/04)
Page: 7 of 14


Document Has Been Signed on 04/24/2023 09:29 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE
FACILITY NUMBER: 502701132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(5)


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

Based on record review, the licensee did not comply with the section cited above in 3 out of 4 resident files. They did not contain the required documentation including but not limited to: appraisals, reappraisals and the updated needs and services plan. These omissions pose an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 04/12/2023
Plan of Correction
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The licensee shall develop a tracking system to ensure that all the rquired materials are present in the resident files. This document will be submitted to CCL at kimberly.viarela@dss.ca.gov by 04/12/2023.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
LIC809 (FAS) - (06/04)
Page: 8 of 14


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE
FACILITY NUMBER: 502701132
VISIT DATE: 03/27/2023
NARRATIVE
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LPAs also observed a patio and walkway along the right side of the house where the garage side door was located. LPAs' observation of backyard included holes and loose boards in the fence and 2 damaged bookcases placed on their sides, along the fence side of the walkway. Behind the bookcases, and leaning against the fence, was a glass tabletop. The facility currently has no ambulatory residents, however if there were residents who enjoyed this area this would pose a safety concern. At the time of inspection, gates did not have automatic closing systems or alerts.

LPAs inspected a locked shed on that side of the facility. LPAs instructed the designated facility administrator to unlock the shed and found it to contain household storage.
The facility administrator led the LPAs through the side door and into the garage. LPAs observed boxes, a mattress, furniture, and medical equipment stacked to one side. LPAs observed a locked storage cabinet against the wall. LPAs instructed the designated facility administrator to unlock the storage cabinet and observed that it contained cleaning supplies. A second fire extinguisher was present in the garage (inspected 03/06/23). LPAs were then shown to a staff room that was constructed from a section of the garage. LPAs viewed the room and ensured that it was not being used by residents. A new facility sketch to reflect this physical plant update was requested.

LPAs re-entered the main house through the laundry room. LPAs witnessed chemicals locked in cabinets above the washer and dryer. Two jugs of bleach were unsecured on the floor of the room. This room had a lock on the door from the kitchen-side and was inaccessible to residents.

The hall bathroom was inspected next. LPAs witnessed the required grab bars and non-skid mats. LPAs measured the hot water temperature and found it to be 107 degrees Fahrenheit, within the required range of 105 to 120 degrees Fahrenheit. The linen closet contained enough bedding to be sufficient and in compliance.

Resident bedrooms were inspected. Resident furniture, furnishings and lighting were

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC809 (FAS) - (06/04)
Page: 10 of 14
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE
FACILITY NUMBER: 502701132
VISIT DATE: 03/27/2023
NARRATIVE
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found to be sufficient and met the needs of residents at this time. One resident had a private bathroom. LPAs witnessed that it possessed grab bars and non-skid mats at this time.

At the time of the inspection, medications were centralized and stored in a locked cabinet next to the refrigerator. Policies and procedures were discussed with staff in terms of dispensing and documenting the administration of resident medications. First aid kit was observed to be present and contained all of the necessary components at this time.

The living areas, kitchen/dining area, and all other areas intended for resident use were toured and observed to be in compliance at this time.

LPAs performed file reviews for 4 residents and 4 staff members. For the resident files, LPAs looked for the following: a signed and dated admissions agreement, a physician’s report, proof of a negative TB test, ambulatory/non-ambulatory status, ID and emergency information, an appraisal and needs service plan, a centrally stored medication destruction record, safeguards for cash resources, safeguards for property/valuables, statement of personal rights, and cash resources information. For the staff files, LPAs looked for the following: first aid certificate, fingerprint clearances/exemptions, personnel record/job application, health screening, proof of negative TB test, medical training verification, employee rights, and criminal record statement.

(Report continues on the following page.)

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
LIC809 (FAS) - (06/04)
Page: 11 of 14
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE
FACILITY NUMBER: 502701132
VISIT DATE: 03/27/2023
NARRATIVE
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26
27
28
29
30
31
32
The following forms and documents were requested to be updated and submitted to CCL via email to kimberly.viarella@dss.ca.gov by 04/15/22:

LIC 308

LIC 400

LIC 500

LIC 610

Updated Liability Insurance.

According to the California Code of Regulations (Title 22, Division 6), the LPA observed the following deficiencies listed on the LIC 809 D. Civil penalties were assessed during today's visit.

An exit interview was conducted with staff member, Nova Ybarra . Copies of the the Facility Evaluation Report and Appeal Rights were provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC809 (FAS) - (06/04)
Page: 12 of 14
Document Has Been Signed on 04/24/2023 09:29 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE
FACILITY NUMBER: 502701132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and records review, the licensee did not comply with the section cited above in 3 out of 4 file reviews where 3 residents in care were diagnosed as bedridden by their physicians. This which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
1
2
3
4
The stated facility designated administrator will submit a request to CCL for a new fire clearance to accommodate the bedridden residents in care by 04/11/2023.
Type A
Section Cited
CCR
87204(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
POC Due Date: 04/11/2023
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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
LIC809 (FAS) - (06/04)
Page: 13 of 14


Document Has Been Signed on 04/24/2023 09:29 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GRACEFUL LIVING AT VILLAGE ONE
FACILITY NUMBER: 502701132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and records review, the licensee did not comply with the section cited above in 5 out of 12 staff files where employees were not properly associated to this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
1
2
3
4
The facility designated administrator wiil request a transfer of a criminal clearance as specified in Section 87355(c) for all employeeswho were not properly assocaited. An Lic 9182 will be be submitted to CCL by 04/11/2023.
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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
LIC809 (FAS) - (06/04)
Page: 14 of 14