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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507206802
Report Date: 09/29/2022
Date Signed: 10/12/2022 02:08:08 PM


Document Has Been Signed on 10/12/2022 02:08 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 OAKDALE 2FACILITY NUMBER:
507206802
ADMINISTRATOR:MATIS, VOICAFACILITY TYPE:
740
ADDRESS:1188 DEITZ CIRCLETELEPHONE:
(209) 595-1028
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:6CENSUS: 6DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Facility staff, Rainileo Clavana TIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with facility staff Rainileo Clavana Continual Administrator's Certification for Voica Matis expires 12/16/2023. There are currently 5 residents who reside at this home and there is 0 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, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 119 degrees. First Aid kit is on site and complete. LPA confirmed staff present has a COVID 19 vaccine card or exemption card on file. LPA confirmed all staff present to be background cleared.

LPA observed cleaning solutions such as glass cleaner, and Fabuloso not secured or locked in the facility garage area.

LPA observed a closet used to store facility medications unlocked and accessible to residents.

There following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's 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 facility staff Rainileo Clavana 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: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
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 2


Document Has Been Signed on 10/12/2022 02:08 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GRACEFUL LIVING AT OAKDALE 2
FACILITY NUMBER: 507206802

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) Incidental Medical and Dental
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation , the licensee did not comply with the section cited above as in LPA observed the facility medication storage closet to be unlocked locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee will conduct staff training on medication storage and send POC to LPA by 09/30/2022 POC date.
Type A
Section Cited
CCR
87309(a)

87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed the glass cleaner, and fabuloso cleaning solutions to be unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee will conduct staff training on chemical storage and submit proof to LPA by 09/30/2022 POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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