507004710-5-5-2025-27-AS-ELIM-DGDTRC-20250505145717

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004710
Report Date: 05/05/2025
Date Signed: 05/05/2025 02:57:39 PM

Document Has Been Signed on 05/05/2025 02:57 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 OAKDALE		FACILITY NUMBER:	507004710
ADMINISTRATOR/ DIRECTOR:	MATIS, VOICA		FACILITY TYPE:	740
ADDRESS:	580 BUCKAROO COURT		TELEPHONE:	(209) 322-3629
CITY:	OAKDALE	STATE: CA	ZIP CODE:	95361
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	05/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:37 AM
MET WITH:	Voica Matis, Adminstrator		TIME VISIT/ INSPECTION COMPLETED:	03:15 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 05/05/2025, Licensing Program Analysts (LPAs) Triel Lindstrom and Arielle Pascua arrived at the facility to conduct an unannounced annual inspection. LPAs Lindstrom and Pascua identified themselves, explained the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). DFA Voica Matis arrived at the facility and a brief interview followed. DFA Matis accompanied LPAs Lindstrom and Pascua on the tour of the facility. This facility is a single-story residential home licensed to serve five non-ambulatory residents and one bedridden resident. It has a hospice waiver for two residents. Its fire clearance was issued by Modesto Fire Department on 09/28/23. The current census is five, including one resident on hospice. There were three staff on duty at the time this inspection, Arnel Arban,Ulna Tarrazona, and Rainilda Clavano. The annual inspection began with a records review. LPA Lindstrom requested all staff files. The review revealed that there are current records for health screening, required training, and first aid/CPR certification. LPA Lindstrom reviewed the Guardian background check list and verified that all staff has a criminal record clearance. LPA Lindstrom requested all resident files. The review revealed that all required paperwork is present. A tour of the facility was conducted. LPA Lindstrom then inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, laundry room, garage, storage areas, and back yard to ensure compliance with Title 22 regulations. The Administrator Certificate, Complaint Hotline Poster, Ombudsman information, menus, and resident personal rights are displayed in a central location.

Lisa Rios	TELEPHONE: (916) 969-9685
Ellen Lindstrom	TELEPHONE: (916) 809-2109
	DATE: 05/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025

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 OAKDALE	FACILITY NUMBER: 507004710
	VISIT DATE: 05/05/2025

NARRATIVE

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The tour began in the kitchen. LPAs Lindstrom and Pascua inspected the storage areas, counter surfaces, and appliances. These areas are clean, odor-free, operable, and pest-free. LPAs inspected the food supply located in the refrigerator, freezer, and pantry. The facility has a two-day supply of perishable food and seven-day supply of non-perishable food. Food containers are dated and labeled, and opened containers are resealed properly. Sharp objects and toxic chemicals are stored in locked cabinets, separately from food items and made inaccessible to residents in care.

The tour progressed to the central medication storage area, which is located in the kitchen. Medication was stored separately from other items in a locked cabinet. LPAs Lindstrom and Pascua examined a sample of residents’ medications and compared it with the Medication Administration Records. The facility initials after administering each dose and keeps a separate log for the administration of PRN, OTC, and controlled medications. The first aid kit contain all required items.

The tour progressed to the living room, dining room, hallways, and bedrooms. These areas have adequate furnishing, lamps, and lighting. Each resident has a bed, bedside table, chair, and chest of drawers, which are in good condition. These areas are clean and odor-free. The windows and window coverings are unbroken and operable.

The tour progressed to the bathrooms. LPA Lindstrom measured the temperature of the hot water in one bathroom sink. Hot water temperature was measured at 111.2 degrees Fahrenheit, which meets regulation. The water fixtures work, the toilets flushes, grab bars are present and sturdy, and non-slip mats were observed and in good condition.

The thermostat was set at 76 degrees. A fire extinguisher is located in the kitchen and was last serviced by Touch Down on 02/04/2025. The facility has an interconnected smoke alarm system and an individual carbon monoxide detector. The detectors were tested and an alarm sounded. The facility also has an ancillary fire alarm system. The facility has a written emergency disaster plan and a log that documents that disaster drills are held quarterly.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Ellen Lindstrom	TELEPHONE: (916) 809-2109
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025

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 OAKDALE	FACILITY NUMBER: 507004710
	VISIT DATE: 05/05/2025

NARRATIVE

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The tour progressed to the laundry room, garage, and storage areas. These areas are clean. Toxic chemicals are stored in locked cabinets. An extra chest freezer and a refrigerator/freezer in the garage contains additional perishable food items.

The tour progressed to outdoor areas. The grounds are well maintained. The lawns are manicured and weeded, the pathways are kept clear of vegetation, and downed vegetation and fallen fruit has been removed. There are two raised garden beds and a small tool shed in the backyard. There is an outdoor space for residents to use with furnishings that are in good repair. The backyard fence is complete, sturdy, and in good repair. The side gate is self-closing and self-latching with hazards present.

LPA Lindstrom requested that updated copies of these documents be emailed to her by 5:00 PM on Friday, May 9, 2025.

(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate
(4) LIC 610 Current Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC 500 Current Personnel Report
(7) LIC 309 Administrator Organization

Based on the observations made during this visit, Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, there are no deficiencies observed during today’s visit.

An exit interview was held, and a copy of the report was provided was provided to the facility at the end of this visit.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Ellen Lindstrom	TELEPHONE: (916) 809-2109
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025

LIC809 (FAS) - (06/04)

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