<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003595
Report Date: 04/27/2023
Date Signed: 04/28/2023 08:22:12 AM


Document Has Been Signed on 04/28/2023 08:22 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 MODESTOFACILITY NUMBER:
507003595
ADMINISTRATOR:MATIS, VOICA V.FACILITY TYPE:
740
ADDRESS:3709 CORRINE LANETELEPHONE:
(209) 545-1352
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 3DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rainileo Clavano, Administrator DesigneeTIME COMPLETED:
06:30 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 04/27/23, at 9:00 AM, an unannounced annual inspection was conducted by Licensing Program Analyst, (LPAs), Kimberly Viarella and Licensing Program Manager, (LPM) Liza King at Graceful Living at Modesto. These Community Care Licensing representatives identified themselves and the purpose of their visit to the facility administrator designee, Rainileo Clavano, (certificate # 6060066740, exp. 06/24/23) and a brief interview followed.

Facility reported census was 3 with 2 hospice and 1 of those being bedridden. Upon inspection the LPA/M noted that 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 has been approved for a hospice waiver for 3 residents. Residents with dementia were observed to be in care at this facility.

The tour began in the kitchen. Knives were secured in a locked drawer. LPA 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. LPM disposed moldy or expired items including by not limited to: green beans, tomatoes, and jarred peaches. Food storage and meal preparations / menu were discussed with the designated facility administrator and staff. LPM took the opportunity to educate staff on proper labeling procedures and the reason for doing so.

Resident medications were kept in a locked drawer in the kitchen. Policies and procedures regarding dispensing meds were reviewed and discussed. LPA observed narcotics locked in a refrigerator in the garage.

Continues on LIC 809C

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9


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 MODESTO
FACILITY NUMBER: 507003595
VISIT DATE: 04/27/2023
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
26
27
28
29
30
31
32
The fire extinguisher was last inspected on 06/17/2022, by Stanislaus Fire.

LPA/M observed the dining and living room areas. Both had adequate furniture, furnishings, and lighting to be in compliance. The ceiling fan and air vents had and accumulation of visible dust.

The tour progressed into the bedrooms. Bedroom 1, at the end of the hall on the left, was in compliance. Grab bars and a bath mat were present in the adjacent private bathroom. LPA observed mold in the shower. Bedroom 2 was in compliance. Bedroom 3 was not in compliance. There were 2 beds and the one closest to the door extended into the doorway, posing a fire hazard. The room also did not have the required night stand(s) or chairs. LPM discovered gas pills and vapor rub in the top drawer of the dresser, which also poses a safety risk to residents in care.. Bedroom 4 was in compliance.

LPA/M inspected the second bathroom. Grab bars were present, a bath mat was not, allowing for a potential fall. There was mold in the shower. The LPA took the temperature of the hot water and it measured 148 degrees and out of compliance. The designated facility administrator immediately turned the hot water down.

The designated facility administrator led the tour through the locked laundry room and into the garage. At this time, laundry detergents were also locked to ensure resident safety. LPA/M observed that the garage was unorganized with oxygen tanks in serval places and without a warning sign to alert the fire department. This posed a potential hazard to residents in care. Items stored in the garage included but were not limited to: a baby strolled, 4 wheel chairs, dressers, chairs, boxes, clothes, shoes, empty boxes, bed frames, mattresses, a privacy screen, suitcases, assorted medical equipment, food on the floor, and more. LPA/M discussed the dangers of having food on the floor and of having a garage with flammable materials stacked and stored in a disorganized fashion. There were storage cabinets along one wall and each was inspected. One locked cabinet contained cleaning supplies. Others contained dry goods and clothes.

LPA/M were shown a freezer where it was observed to contain meat wrapped in plastic without any labeling identifying the product or expiration date. Another refrigerator/freezer unit contained similar items.

The LPA/M were led by the designated facility administrator out the side door of the garage. The gate was tested and found to be inoperable. There were two window screens on that side of the house that had holes in them and/or did not fit the window properly. Screens were also missing from the kitchen sliders, the dining room window, the living room window and the second bedroom. Continued LIC 809C.

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

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 9
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 MODESTO
FACILITY NUMBER: 507003595
VISIT DATE: 04/27/2023
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
26
27
28
29
30
31
32
LPA/M observed an unlocked greenhouse in the backyard. It contained fertilizer, pesticides and other toxins. Along the side of the house, LPA/M observed gardening shears, pet food, a gas can, Pine Sol and other debris.

A records review was performed for 4 staff and 3 resident files. 4 out of 4 staff files were missing their annual training. All First Aid training was current. The resident files were also incomplete. None of the files included pre-appraisal assessments. 3 of the files had needs and assessments that were dated 04/25/23 and there were no prior assessments included in their files. Personal inventories were not completed upon admittance and were not included.

The designated facility administrator was asked to produce the 2 hospice care plans for the 2 residents in care and was unable to do so. Staff reported during interview that pain management was being implemented prior to repositioning, however a review of the Medication Administration Record (MAR) did not confirm that this was happening. An interview with the hospice nurse revealed that training has previously been conducted on pain management regarding repositioning. The facility has been cited on the D page for not following the hospice care plan.

The following forms and documents were requested to be updated and submitted to CCL via email to kimberly.viarella@dss.ca.gov by 05/29/2023.

LIC 308 LIC 400

LIC 500 LIC 610

All staff training

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 the administrator designee, Rainileo Clavano. Copies of 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: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 04/28/2023 08:22 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 MODESTO
FACILITY NUMBER: 507003595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of three resident files and interview of staff and the Administrator, unusual incident and death reports are not being submitted to licensing per the requirement, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
1
2
3
4
The licensee will provide Kimberly Viarella proof of staff training on Reporting Requirements, an updated Resident Roster, and the three death repots requested during the facility visit. All incident reports and death reports shall be available for licensing review during an inspection.
Type B
Section Cited
CCR
87705(c)(5)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Licensees who accept and retain residents with dementia ... annual medical assessment and appraisal...

Based on record review the licensee did not comply with the section cited above in 1 of 3 residents did not have a medical assessment completed and 2 of 3 did not have a medical reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
1
2
3
4
A tracking system will be developed to ensure that residents are receiving annual assessments. This tracking system will be submitted to Community Care Licensing at kimberly.viarella@dss.ca.gov.
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: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 04/28/2023 08:22 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 MODESTO
FACILITY NUMBER: 507003595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(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: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review the licensee did not comply with the section cited above in one out of three persons are identified as being bedridden. The facility has fire clearance for 6 nonambulatory residents and no bedridden residents. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
1
2
3
4
The licensee will provide an updated request for a fire inspection, to include clearance for a bedridden resident (submit an LIC200 and $25 check for processing fees)
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
1
2
3
4
Based on observation the licensee did not comply with the section cited above, during inspection the water temperature was measured at 148 degrees in the main shared bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
1
2
3
4
The Licensee lowered the temperature while the LPA was onsite. The Licensee will maintain a temperature log daily and submit to kimberly.viarella@dss.ca.gov weekly on Friday for 4 weeks. Following the 4 week period the licensee will develop a plan to monitor the temperature of the water on a regular basis.
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: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 04/28/2023 08:22 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 MODESTO
FACILITY NUMBER: 507003595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the facility had accessible to residents cleaning solutions, gasoline, pesticides and pruning sheers in the back yard area, in the greenhouse and in the top drawer of one resident dresser, whom was not allowed access to personal care supplies per the 602, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
1
2
3
4
All dangerous chemicals and sharps that could be harmful to residents in care will be put in a locked area. Photographs of a lock on the greenhouse will be submitted to Kimberly.Viarella@dss.ca.gov as proof of correction.
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: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
LIC809 (FAS) - (06/04)
Page: 6 of 9


Document Has Been Signed on 04/28/2023 08:22 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 MODESTO
FACILITY NUMBER: 507003595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87633(a)(4)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident's hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident's or prospective resident's Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review of 2/2 residents files and interview with the Administrator, the licensee did not comply with the section cited above and was unable to produce the hospice care plans, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
1
2
3
4
The Licensee will email to kimberly.viarella@dss.ca.gov the 2 hospice care plans. In addition, training of staff on the care plans and recommendations of hospice will be conducted by 4/29/23 and submitted to Kimberly by 5/01/23.

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: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
LIC809 (FAS) - (06/04)
Page: 7 of 9


Document Has Been Signed on 04/28/2023 08:22 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 MODESTO
FACILITY NUMBER: 507003595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
1
2
3
4
Based on record review and interview with the Administrator the licensee was unable to provide the documented annual training (last documented training Feb 2022 and no medication training was available for review) for 4 of 4 staff. This poses a potential risk to the clients in care. .
POC Due Date: 05/29/2023
Plan of Correction
1
2
3
4
The licensee will develop a tracking system for monitoring staff training and all staff will complete the required annual training by the POC date. The licensee will provide proof of training via email at kimberly.viarella@dss.ca.gov.
Type B
Section Cited
CCR
87405(d)(2)
Resident Records


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Administrative Qualifications: Administrator shall have... knowledge of and ability to conform to the applicable laws, rules and regulations...

Based on observation, interview, and record review, the licensee did not comply with the section cited above as evidenced by the inability to produce required documents and the number of deficiencies cited during this annual inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2023
Plan of Correction
1
2
3
4
Licensee will submit an updated LIC500 to identify the hours administrators will be present. Licensee will also take an RCFE Laws and Regulations course through an outside vendor. Licensee will provide proof of registration and completion.
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: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
LIC809 (FAS) - (06/04)
Page: 8 of 9


Document Has Been Signed on 04/28/2023 08:22 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 MODESTO
FACILITY NUMBER: 507003595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above when 5 items of expired and moldy food had to be discarded from the kitchen refrigerator. Over 20 packages of frozen meats wrapped in plastic wrap and without expiration date or labels of any kind were also found in the garage freezer which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2023
Plan of Correction
1
2
3
4
The kitchen refrigerator and freezer will be cleaned out and all food items will be dated when packages are opened. It will be checked for expired items on a regular monthly schedule. The freezer in the garage will be emptied, defrosted, and all items will be labeled depicting what the item is and when it was frozen. Photos showing proof of correction will be submitted to Community Care Licensing at kimberly.viarella@dss.ca.gov by the date above.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the documented fire drills are Jan 2022 and Feb 2023 13 months in-between, this poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2023
Plan of Correction
1
2
3
4
The licensee will develop a tracking system for monitoring when disaster drills are due and submit to Kimberly.viarella@dss.cs.gov by POC date.
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: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
LIC809 (FAS) - (06/04)
Page: 9 of 9