507206802-4-29-2022-27-AS-SDOB-CE4K4E-20220504073412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507206802
Report Date: 04/29/2022
Date Signed: 04/29/2022 04:17:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2022 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20220419085726

FACILITY NAME:	GRACEFUL LIVING AT OAKDALE 2		FACILITY NUMBER:	507206802
ADMINISTRATOR:	MATIS, VOICA		FACILITY TYPE:	740
ADDRESS:	1188 DEITZ CIRCLE		TELEPHONE:	(209) 595-1028
CITY:	OAKDALE	STATE: CA	ZIP CODE:	95361
CAPACITY:	6	CENSUS: 6	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Rainilda Clavano, Caregiver		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff gave resident wrong medications
Facility did not report medication error to licensing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to investigate the above mentioned allegations on 4/29/22 at 2:20pm. LPA was met by Linda Aguilar and stated the purpose of the visit. The Administrator Voica Matias was made aware of the complaint as well. LPA observed the locked medication cabinet and the containers for each resident. LPA observed the Medication Administration Record (MAR), and the Tablets-Capsules-Ampules Log. LPA interviewed staff #1 (S1-S3) during this visit. LPA did not observe the use of 7-day pill box during this visit.

Based on interviews, observation and lack of evidence the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED.
A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, and a copy of this report was provided.

Unsubstantiated

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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