507003595-4-7-2025-27-AS-APAA-DFHTH8-20250407144418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507003595
Report Date: 04/07/2025
Date Signed: 04/07/2025 02:45:50 PM

Document Has Been Signed on 04/07/2025 02:45 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 MODESTO		FACILITY NUMBER:	507003595
ADMINISTRATOR/ DIRECTOR:	BOGDAN CONDOR		FACILITY TYPE:	740
ADDRESS:	3709 CORRINE LANE		TELEPHONE:	(209) 545-1352
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	04/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:			TIME VISIT/ INSPECTION COMPLETED:	01:15 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 04/07/2025, Licensing Program Analysts (LPAs) Arielle Pascua and Triel Lindstrom arrived unannounced to this facility to conduct an annual visit. LPAs met with staff member (SM), Remedios De Belen and explained the purpose of the visit. LPA Pascua asked SM De Belen to contact the Facility Designated Administrator (FDA), Bogdan Condor and inform them that CCL was present at this time. Shortly after, LPAs met with FDA Condor and explained the purpose of the visit. The purpose of the visit was to conduct an annual. Current census was 5. A brief interview with FDA Condor was conducted. This facility is licensed to serve and retain 6 elderly residents who all may be deemed non-ambulatory. This facility also has a hospice waiver for 3 and a dementia plan on file. Upon arrival at the facility LPA Pascua rang the ring doorbell located on the right side of the double front doors. After several attempts LPA Pascua knocked on the door and heard an individual on the inside of the facility state that they heard the knock but was unable to open the door. LPA continued to knock on the door 3 more times until the door was opened by facility staff. Upon entrance to the facility both LPAs walked through the double front doors and observed a grey reinforcement locking mechanism above the top lock of the door. LPAs observed that this lock would prohibit the door from being open. Shortly after, LPAs met with FDA Condor and informed him of the lock on the door. LPA Pascua informed FDA Condor that the lock was a safety hazard which prohibited both staff and residents to exit the facility in case of emergency. LPA Pascua asked FDA Condor to take the lock out before the tour of the facility was conducted.

Lisa Rios	TELEPHONE: (916) 969-9685
Arielle Pascua	TELEPHONE: (916) 862-5907
	DATE: 04/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/07/2025

NARRATIVE

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During this time, Licensee Voica Matis, arrived at the facility.
A tour of the facility was conducted. Fire extinguisher was identified and was last serviced on 02/18/2025 by the local fire extinguisher company.
Living room areas, dining areas, and other residents intended for resident use were toured. Furniture and furnishings were observed to be in good repair and able to meet resident needs.
Kitchen area was toured. A review of the food supply was conducted to ensure that the facility has a 2 day perishable and 7 day non-perishable food supply to meet the residents needs. Knives were observed to be locked and made inaccessible.
LPA Pascua identified one medication cabinet located in the kitchen. Along with Licensee Matis, LPAs reviewed and compared medication with medication dispensing logs. It was learned through review of the facility records that the facility staff had not initialed medication dispensing logs throughout the weekend of 4/4/2025 through today's date of 04/07/2025. In addition, the dates that were initialed were initialed for medication that was supposed to be provided during 8:00pm. LPA Pascua provided assistance to the facility staff and reminded them of the importance of ensuring that medication administration records must be initiated at the time of administration. A review of medication also showed that the facility was pre-pouring medication for the next administration. LPA Pascua stated that the department no longer allowed pre-pouring. Licensee and staff member understood and stated that this would be attended to. First aid kit was also present and contained all the required components.
A tour of back yard was conducted. LPAs observed a separate casita in the backyard, which staff use for breaks or live in staff. LPA asked the Licensee send an updated facility sketch to reflect changes. Perimeter fence was observed to be in good repair. The emergency gate was observed, however, upon opening the gate, it was observed that the gate was not easy to open and did not self latch or self close. LPA Pascua advised that the exit gate shall be fixed to ensure that the facility staff and residents were able to open the gate easily and that it would self latch and self close.
A tour of the resident bedrooms were conducted. Bedroom #1 has an adjacent bathroom. Bedrooms #2-4 were single occupancy bedrooms. Furniture and furinishings were observed to be in good repair.
A tour of the facility bathroom was conducted. Hot water was taken to ensure that it was within 105-120 degrees. LPAs observed rusting on the bottom of the facility shower that may have been from the shower chairs. In addition, black residue was observed in the corners and grout areas of the bathroom shower.
A linen closet was identified and contained a sufficient supply of linens to meet the residents needs.
A tour of the laundry area was conducted. Cleaning supplies, laundry detergent, and other items were locked and made inaccessible.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

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: 04/07/2025

NARRATIVE

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A tour of the garage was conducted. Additional food supply was identified.

LPAs reviewed 6 resident files and 7 staff files was conducted. The administrator has a expired administrator certificate.

The following documents were requested to be submitted to the department:
-LIC 308
-LIC 400
-LIC 500
-LIC 610E
-Updated Facility Sketch
-Updated Program Design to reflect staffing such as live in staff
-Updated Administrator documentation

A immediate civil penalty is being issued today in violation of Section 87202(a). This is due to the reinforcement lock observed at the time of the visit.

A technical assistance is being provided for Section 87303(a) and 87465(h)(5).

The following deficiencies were observed and cited per California Code of Regulations, Title 22 see LIC 809-D.

Exit interview conducted with Licensee and copy of report and appeal rights were left at facility.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/07/2025 02:45 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACEFUL LIVING AT MODESTO	FACILITY NUMBER: 507003595
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87202(a)

(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. 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 in by not ensuring that the front door did not have accessiblity to open the door for an emergency exit. LPAs observed a grey reinforcement lock on top of the original door lock that prohibited facility staff and residents from opening the door easily. This poses an immediate health, safety, and personal rights risks to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Licensee shall provide a statement of acknowledgement to the LPA by POC date. The reinforcement lock was removed at the time of the visit. A Civil penalty was issued.

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.

Lisa Rios	TELEPHONE: (916) 969-9685
Arielle Pascua	TELEPHONE: (916) 862-5907
	DATE: 04/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/07/2025 02:45 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACEFUL LIVING AT MODESTO	FACILITY NUMBER: 507003595
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

80075(5)(C)

Health Related Services 80075(5)(C):If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication...A record of each dose is maintained in the client's record... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not ensure that the Medication Administration Record was not completed at the time of administration. LPAs reviewed the Facility Administration Administration Record and observed that staff did not sign for medication that was administered from 04/03/2025-04/07/2025. This poses a potential health, safety, and personal rights risks to persons in care.
	POC Due Date: 05/07/2025
	Plan of Correction
1 2 3 4	Licensee shall provide a statement of acknowledgement and correction to the LPA by POC date.

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.

Lisa Rios	TELEPHONE: (916) 969-9685
Arielle Pascua	TELEPHONE: (916) 862-5907
	DATE: 04/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

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