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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003595
Report Date: 11/15/2023
Date Signed: 11/15/2023 12:27:08 PM


Document Has Been Signed on 11/15/2023 12:27 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 MODESTOFACILITY NUMBER:
507003595
ADMINISTRATOR:BOGDAN CONDORFACILITY TYPE:
740
ADDRESS:3709 CORRINE LANETELEPHONE:
(209) 545-1352
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 3DATE:
11/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Voica MatisTIME COMPLETED:
12:45 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 11/15/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly visit to monitor for compliance with previously identified deficiencies. LPA Jensen met with Licensee Voica Matis and explained the purpose of today's visit.

The facility is being monitored for compliance in the following areas:
Presence of the Administrator
Fire Clearance with respect to retention and acceptance of bedridden clients
Pre-placement appraisals
Needs and Service Plans
Physician Reports
Reporting Requirements
Record Keeping

LPA Jensen interviewed 2 of 2 staff members who advised the Administrator is typically present at the facility from 9am-5pm Monday to Friday. The facility currently has 3 clients, 2 of which are ambulatory and 1 of which is non-ambulatory. There are no bedridden clients currently residing at the facility. LPA reviewed both staff files for the care providers present at the time of the visit and found them to be complete and in compliance. LPA Jensen reviewed 3 of 3 client files and determined them to be complete and in compliance. LPA Jensen reviewed documentation detailing a communication exchange between the Licensee and a hospice provider wherein the hospice provider has agreed to conduct staff training on postural support, patient transitioning and infection control to be scheduled after 11/20/23. LPA Jensen reviewed training records and found the training to be in compliance.

The facility was observed to be sanitary and in good repair. No deficiencies are being cited. An exit interview was conducted and a copy of this report was given.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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 1