507004711-8-1-2023-27-AS-MJEN-CUAUPW-20230801154613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004711
Report Date: 08/01/2023
Date Signed: 08/01/2023 03:46:19 PM

Document Has Been Signed on 08/01/2023 03:46 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GRACEFUL LIVING AT RIVERBANK		FACILITY NUMBER:	507004711
ADMINISTRATOR:	MATIS, VOICA		FACILITY TYPE:	740
ADDRESS:	5708 AMBERWOOD LANE		TELEPHONE:	(209) 869-4859
CITY:	RIVERBANK	STATE: CA	ZIP CODE:	95367
CAPACITY:	4	CENSUS: 4	DATE:	08/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:			TIME COMPLETED:	04:00 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 8/1/23 at approximately 1:00pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with care provider Rosalinda Ortega and LPA spoke to Licensee Voica Matis by phone. The Administrator, Voica Matis, holds current Administrator's certificate # 6008538740 which is good through 12/16/23. LPA Jensen toured the grounds and physical plant. The grounds were observed to be well maintained and all paths were clear of obstruction. There is outdoor furniture so that residents may enjoy leisure activities outdoors. There are no bodies of water on the property. There are 3 bedrooms of which 2 are single occupancy and 1 is double occupancy. There are currently 4 residents. The front entrance is equipped with sign in logs and sanitizer. The entrance way also has postings that include infection control measures, Resident Council, Long Term Care Ombudsman, Personal Rights, Emergency Disaster Plan and facility sketch. The carbon monoxide detector and smoke detector was tested and determined to be in good working order. The fire extinguisher was last serviced in June of 2023 and is in compliance. The first aid kits were observed to be complete. The facility maintains emergency lighting and supplies on site. LPA Jensen toured the kitchen and observed all knives and sharp objects to be locked and inaccessible to residents in care. Chemicals, cleaning supplies and toxins are stored locked in the garage. The facility maintains in excess of a 2 day supply of perishable food and 7 day supply of non-perishable food. All food is labeled with the expiration date. There was fresh vegetables and fruit available for residents. The medication is stored in a locked cabinet and was observed to be inaccessible to residents in care. LPA Jensen conducted a random count of controlled medications and found the record keeping to be accurate. The effectiveness of all PRN medication is documented. LPA Jensen reviewed the Medication Administration Records (MARs) and found them to be accurate.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GRACEFUL LIVING AT RIVERBANK	FACILITY NUMBER: 507004711
	VISIT DATE: 08/01/2023

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
26
27
28
29
30
31
32

LPA Jensen observed 3 of 3 bedrooms and determined all to be equipped with the required furniture. 1 of 4 residents has an exception authorized by his physician for the use of wheel chair instead of a bed. There is an adequate supply of linens maintained. The bathrooms were observed to be sanitary and equipped with grab bars at the toilet and in the shower. There were no toxins observed to be accessible in the 2 bathrooms. LPA Jensen measured the bathroom water temperature at 107 degrees Fahrenheit which falls within the required range of 105-150 degrees Fahrenheit. The thermostat was set at 75 degrees Fahrenheit for the comfort of the residents.

LPA Jensen interviewed 2 of 2 staff members and 2 of 4 residents. The remaining 2 residents were not available for interviews. During the course of the staff interviews, activities were stressed as a key component of care. The resident roster was last updated in June of 2023 and accurately reflects the facility resident population. LPA Jensen reviewed 4 of 4 resident files and 2 staff files.

LPA Jensen verified that the facility has scheduled some interior renovations including replacing the flooring and interior paint for later this month, mid to late August 2023. The Licensee does not anticipate any disruption of care for the residents but will notify the Department if any disruption or relocation is required. The facility was determined to be in substantial compliance and no deficiencies were cited as a result of this inspection.

The facility was determined to be in substantial compliance and no deficiencies were issued as a result of this visit.

An exit interview was conducted and a copy of this report and appeal rights were given to Rosalinda Ortega.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4