507206802-11-7-2023-27-AS-MJEN-CXCSWH-20231107131423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507206802
Report Date: 11/07/2023
Date Signed: 11/07/2023 01:14:37 PM

Document Has Been Signed on 11/07/2023 01:14 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 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:	11/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Voica Matis		TIME COMPLETED:	01:30 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 11/7/23 at approximately 10:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with Licensee Voica Matis and explained the purpose of today's visit. The Licensee holds a current Administrator certificate good through 12/16/2023. The annual fees were verified to be current. LPA Jensen toured the grounds and determined all paths to be free of obstruction. The grounds were observed to be maintained. There is outdoor seating available with shaded areas for client engagement. All screens were in good repair. LPA Jensen toured the interior. The facility was observed to sanitary and was free of odor. There was adequate lighting and furniture throughout. There are night lights available in the hallway. The facility maintains adequate linens and hygiene supplies. All appliances are in good working order. LPA Jensen toured the kitchen and observed in excess of a two day supply of perishable food and a 7 day supply of non-perishable food. There was a variety of fresh fruit and vegetables available. LPA Jensen observed the meal service preparation for lunch which consisted of chicken noodle soup and sandwich. All medications were locked and inaccessible. All toxins and sharp objects were locked and inaccessible. The fire extinguisher and carbon monoxide detector were observed to be in compliance. The first aid kit was observed to be complete and in compliance. The facility maintains and an adequate supply of emergency food. The emergency disaster plan has recently been updated and is in compliance. LPA Jensen reviewed 6 of 6 resident files and determined them to be complete. LPA Jensen reviewed 3 of 4 staff files and determined them to be complete. LPA Jensen observed 1 staff member to be present in the facility that did not have a criminal background clearance. Continued on LIC 809C....

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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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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 2	FACILITY NUMBER: 507206802
	VISIT DATE: 11/07/2023

NARRATIVE

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LPA Jensen provided technical assistance in relation to the facility Infection Control Plan.

Deficiencies are being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Civil penalties are also being assessed for criminal background clearance. The inspection tool was used during the course of this inspection.

An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/07/2023 01:14 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACEFUL LIVING AT OAKDALE 2	FACILITY NUMBER: 507206802
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2023
	Plan of Correction
1 2 3 4	The Licensee immediately dismissed the staff member from duties and agrees to send an attestation to maja.jensen@dss.ca.gov confirming this regulation has been read, understood and will be complied with.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Rios	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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