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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003595
Report Date: 07/07/2021
Date Signed: 07/07/2021 02:45:32 PM

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 MODESTOFACILITY NUMBER:
507003595
ADMINISTRATOR:MATIS, VOICA V.FACILITY TYPE:
740
ADDRESS:3709 CORRINE LANETELEPHONE:
(209) 545-1352
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 5DATE:
07/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:MATIS, VOICA, ADMINISTRATORTIME COMPLETED:
11:45 PM
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On 7/7/21 at 9:40am Licensing Program Analysts (LPA's) Sarah Hurt and Kevin Gould conducted an unannounced required 1 year annual inspection. LPA's met with Administrator Voica Matis . There are currently 5 residents who reside at this home and there is one resident on hospice at this time. LPA's inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguishers last inspected June 2021 . Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 137 degrees F . First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible to residents in care..

LPAs requested the following documents to update facility file: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan if needed and copy of current Administrator’s Certificate to update the facility file.

The following deficiencies were observed and cited per California Code of Regulations, Title 22 see LIC 809-D.

Exit interview conducted with Administrator and copy of report and appeal rights were left at facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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 MODESTO
FACILITY NUMBER: 507003595
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs testing of water temperature, the licensee did not comply with the section cited above as the temperature recorded during inspection was 137 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2021
Plan of Correction
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LPA's witnessed a staff member turn down the water heater. A POC visit will be scheduled to ensure the temperature is within regulation.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
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