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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003595
Report Date: 06/28/2023
Date Signed: 06/28/2023 05:21:03 PM


Document Has Been Signed on 06/28/2023 05:21 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 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:
06/28/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Voica Matis, Bogdon Condor LicenseesTIME COMPLETED:
02:00 PM
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An Informal Conference (IC) was conducted on this day, 06/26/2023, by the Sacramento South Regional Office via Teams meeting. The Administrative Process was explained. The purpose of this Informal Conference was to discuss the high volume of deficiencies referenced below and commonality of deficiencies between the licensees’ facilities. Present in the meeting was Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Kimberly Viarella. Representing Graceful Living was Licensee/Administrator Voica Matis, Licensee Bogdan Condor, and Long term Care Ombudsman, Melissa Flaherty.

The focus of the concerns at this time are as followed:
· Designated Facility Administrator - Qualifications/Duties
· Fire Clearance (bedridden)
· Preplacement Appraisal Information (LIC603)
· Individualized Appraisal Needs and Services Plans (LIC 625)
· Annual Physician’s Exams for dementia care residents (LIC 602s)
· Reporting Requirements/Communication
· Record Keeping – Staff and Resident Files

Licensee agrees to do the following to bring the facility into compliance:
· The Licensee will associate Bogdon Condor as Designated Administrator for Graceful Living Modesto by 07/07/2023.
·The Administrator will be present 40 scheduled hours a week.
·All staff have completed the necessary training by 08/01/2023.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
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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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: 06/28/2023
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Licensee agrees to do the following to bring the facility into compliance:

·The facility will submit a tracking system to monitor:
Physician’s Reports (LIC 602s)
Appraisal Needs and Services Plans (LIC 625s) and reappraisals, (updated LIC 625s).
All required staff training.
All required personnel file documentation
· Provide staff training on Reporting Requirements by 07/07/2023
· Maintain a centralized record of Incident Reports and Death Reports

The facility will continue to have additional monitoring and facility inspections on a quarterly basis. These visits will focus on:

· Resident and Staff Files
· Training
· Maintenance and Operation Logs
· Incident Reports and Death Reports

CCL will increase monitoring to quarterly to enure compliance. No deficiencies were cited from the California Code of Regulations, Title 22, Division 6 as a result of today's meeting. An exit interview was conducted with Voica Matis via telephone and a facility report was provided via email read receipt.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
LIC809 (FAS) - (06/04)
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