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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003595
Report Date: 04/04/2024
Date Signed: 04/04/2024 04:33:11 PM


Document Has Been Signed on 04/04/2024 04:33 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: 5DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Neal ClavanoTIME COMPLETED:
04:45 PM
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On 4/4/24 at approximately 11:45am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with Neal Clavano and explained the purpose of today's visit. LPA Jensen also spoke to the LIcensee Voica Matis by telephone and explained the purpose of today's visit. The Administrator holds current Administrator's certificate number 6022459740 good through 8/22/24.

There are currently 5 residents, 1 of which is on hospice and 1 of which uses oxygen. The facility is licensed for 6 clients, all of which may be non-ambulatory and 3 of which may be receiving hospice services. The facility also provides dementia care. LPA Jensen toured the facility grounds and observed the grounds to be maintained. There is outdoor furniture available for client activities. LPA Jensen observed a gate in the backyard and tested the gate to ensure the self latching mechanism was functional. The backyard gate did close without assistance and should be monitored for continued functionality. There are no bodies of water on the property.

LPA Jensen toured the interior and observed the facility to be sanitary and free of odor. There was adequate furnishings and lighting throughout. The facility has prominently information related to the Ombudsman, resident rights, resident council and fair labor practices. There was no Residential Care Facility for the Elderly Compliant poster displayed or available. Technical assistance was provided. The thermostat was set at 72 degrees Fahrenheit which falls within the required range of 68-85 degrees Fahrenheit. The water temperature in the main hall bathroom was measured at 111.9 degrees Fahrenheit which falls within the the required regulatory temperature. There is an adequate supply of linens at the facility. The bathrooms are equipped with grab bars and non-slip flooring in the bathroom and shower areas. The bedrooms are furnished with beds, dressers, night stands, lamps and chairs. LPA Jensen observed a 2 days supply of perishable food and a 7 day supply of non-perishable food.


SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GRACEFUL LIVING AT MODESTO
FACILITY NUMBER: 507003595
VISIT DATE: 04/04/2024
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LPA Jensen tested the carbon monoxide detector and smoke detector ad determined them to be in good working order. The fire extinguisher was recently purchased and is compliant. The facility maintains an emergency supply of water and emergency lighting. The Emergency disaster plan was reviewed and is comprehensive, current and compliant. The facility conducts quarterly drills with the last drill having been conducted on 2/5/24. All knives, toxins and medications were observed to be locked and inaccessible to residents in care. The fire department has been notified that there is oxygen in use. There is no-smoking signs posted on the room utilized by the resident with a need for oxygen. LPA Jensen reviewed the liability insurance and determined it to be current.

LPA Jensen conducted interviews with 2 of 2 care providers present at the time of facility. LPA Jensen also interviewed 3 of 5 residents who stated they are satisfied with all aspects of their care. LPA Jensen reviewed 5 staff files and determined 5 of 5 had current first aid certificates and health screens. LPA reviewed 5 of 5 resident files and determined them to be complete.

LPA Jensen provided technical assistance on navigating the CDSS website and locating provider resources. The facility was determined to be in substantial compliance. No deficiencies were cited. The inspection tool was used during the course of this visit. An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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