502701132-3-27-2024-27-AS-MJEN-D3RR49-20240327124106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701132
Report Date: 03/01/2024
Date Signed: 03/27/2024 12:41:40 PM

Document Has Been Signed on 03/27/2024 12:41 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 VILLAGE ONE		FACILITY NUMBER:	502701132
ADMINISTRATOR:	SUASIN, LETECIA		FACILITY TYPE:	740
ADDRESS:	3128 AMOS CT		TELEPHONE:	(209) 595-1028
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	6	CENSUS:	DATE:	03/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Voica Matis		TIME COMPLETED:	02:45 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 3/1/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with Licensee Voica Matis and explained the purpose of the visit. LPA Jensen toured the grounds and observed them to be well maintained. All paths were free of obstruction. There is outdoor furniture and shaded areas. All window screens were observed to be in good repair. LPA Jensen toured the physical plant. The thermostat was set at 74 degrees which falls within the required range of 68-85 degrees Fahrenheit. There was adequate lighting and furnishings throughout. All furniture and appliances were observed to be in good repair. The facility was sanitary and free of odor. The bedrooms contained all required furniture. The bathrooms were equipped with grab bars and had non-slip flooring in the bath/shower. There is an adequate supply of linens and grooming supplies. The water temperature in the common bathroom was measured at 108 degrees which falls within the required range of 105-120 degrees Fahrenheit. There are night lights in the hallways. LPA Jensen reviewed the disaster plan and determined it to be in compliance. The facility maintains an emergency supply of water and lighting. The first aid kit was observed to be complete. The carbon monoxide detector and smoke detector were tested and found to be in good working order. The fire extinguisher was last serviced in February of 2024 and is in compliance. All toxins and medications were observed to be locked and inaccessible to clients in care. LPA Jensen toured the kitchen. There was in excess of a two day supply of perishable food and a 7 day supply of non-perishable food. There was no expired food product observed. LPA Jensen conducted this visit while lunch was being served which consisted of a BLT sandwich, soup and fresh baked cookies.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

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 VILLAGE ONE	FACILITY NUMBER: 502701132
	VISIT DATE: 03/01/2024

NARRATIVE

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LPA Jensen reviewed 4 staff files and determined them to be complete. LPA Jensen reviewed 3 resident files and determined them to be complete.

The facility sketch accurately reflects the facility layout. The census is consistent with the fire clearance. All required postings were observed to be displayed in easily viewable locations. Liability insurance was reviewed and is compliant.

LPA Jensen conducted a random medication audit and determined that medication for R1 was not accurately logged in the Centrally Stored Medication and Destruction Record. The medications were observed to be locked and inaccessible to residents in care.

LPA Jensen interviewed two residents that indicated they were satisfied with all aspects of care. The facility has hired a new Administrator. All required paperwork has been submitted for the change in Administrator. The Department is pending notification from the Administrator Certification Unit in order to process the change in the Licensing System.

A deficiency was cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/27/2024 12:41 PM - 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 VILLAGE ONE	FACILITY NUMBER: 502701132
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensens review of medication for Resident 1 (R1) in comparison with the Centrally Stored Medication and Destruction Record, did not accurately record therefore the licensee did not comply with the section cited above in 1 of 1 count which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/02/2024
	Plan of Correction
1 2 3 4	The Licensee agrees to log the dates when all medications are started and agrees to check the records against the Medication Administration Record.

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) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC809 (FAS) - (06/04)

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