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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003595
Report Date: 08/16/2023
Date Signed: 08/16/2023 10:50:43 AM


Document Has Been Signed on 08/16/2023 10:50 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:BOGDAN CONDORFACILITY TYPE:
740
ADDRESS:3709 CORRINE LANETELEPHONE:
(209) 545-1352
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 0DATE:
08/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Voica Matis, Facility Administrator TIME COMPLETED:
11:00 AM
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On 8/16/2023, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced quarterly visit to this facility as a follow up to an informal conference conducted on 6/26/2023 regarding concerns over a high volume of deficiencies. The LPA identified herself, the purpose of the visit and asked to meet with the Designated Facility Administrator.

Voica Matis, one of the Certified Administrators was on the premises and informed the LPA that the census was 0; there were no residents in care at this time. This facility had one resident pass away, one moved out of the area with family, and the third relocated to Graceful Living Village One where she could make friends. The Administrators took this opportunity to do a deep cleaning and remodeling of the facility. No structural changes have been made that would require a permit. LPA observed new flooring, new cabinets, and fresh paint. LPA also noticed a portion of the medical equipment and furniture previously stored in the garage had been removed. LPA did not observe any caregivers on the premises and the Administrator stated that they were working at her other facilities until Graceful Living at Modesto was ready to care for residents again. The Administrator stated that she expects that will be some time in September.

The purpose of today's visit was to review the following:

· Resident and Staff Files


· Training
· Maintenance and Operation Logs
· Incident Reports and Death Reports

Continued on the LIC 809 C

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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 2


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: 08/16/2023
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  • There were no resident or staff files to review at the present time, although the Administrator provided the LPA with binders filled with all the correct documentation for future residents.
  • The Administrators previously submitted updated training materials to Licensing.
  • Maintenance was being completed at the time of visit.
  • LPA reviewed the Death Report for the last resident and verified by the receipt provided, that it had been sent to Licensing. It contained all of the required components to be in compliance.


There were no deficiencies observed or cited during this visit.

A copy of this report was provided to the Administrator.

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

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
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