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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507206802
Report Date: 11/03/2021
Date Signed: 11/03/2021 02:06:58 PM

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 OAKDALE 2FACILITY NUMBER:
507206802
ADMINISTRATOR:MATIS, VOICAFACILITY TYPE:
740
ADDRESS:1188 DEITZ CIRCLETELEPHONE:
(209) 595-1028
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:6CENSUS: 5DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Wellness Coordinator Ging ClavanoTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facilities annual inspection. LPA met with Wellness Coordinator Ging Clavano. There are currently 5 residents who reside at this home and there are no residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period (June 17, 2021.) Smoke alarms were tested and are operational. Water temperature was tested at 118 F degrees. The home has a carbon monoxide detector and performs disaster drills as required. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Wellness Coordinator Ging Clavano and copy of report left at facility
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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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