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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700771
Report Date: 09/06/2023
Date Signed: 09/06/2023 10:39:23 AM

Document Has Been Signed on 09/06/2023 10:39 AM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GRACE CARE HOMEFACILITY NUMBER:
342700771
ADMINISTRATOR:PALAFOX LAPID, GRACIAFACILITY TYPE:
740
ADDRESS:7708 RUDYARD CIRCLETELEPHONE:
(916) 692-8063
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 4DATE:
09/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator- Gracia, Lapid TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Talwinder Bains arrived on 09/06/23 to conduct the annual inspection. LPA met with administrator, Gracia, Lapid and explained the purpose of today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (2) and staff files (2). All residents files contained all required paperwork. LPA found out that some required documents were missing in staff's (S1,S2) files during inspection,therefore deficiencies were cited as indicated on LIC809D. Facility was clean and well organized. All required postings were observed.

LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use. Hot water temperature was observed to be 119 degrees F, which is within the regulation range of 105-120 degree.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 09/20/23.

Deficiencies are cited on LIC809D per Title 22. Exit interview conducted.
Appeal Rights and copy of this report left at facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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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Document Has Been Signed on 09/06/2023 10:39 AM - It Cannot Be Edited


Created By: Talwinder Bains On 09/06/2023 at 10:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACE CARE HOME
FACILITY NUMBER: 342700771

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review for staff (S1,S2) files, S1 file missing -1st aid certificate, training documents and LIC9052 and S2 file missing- 1st aid certificate, LIC501,LIC503,LIC508,LIC9052, TB, Training documents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2023
Plan of Correction
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Licensee shall complete -1st aid certificate, training documents and LIC9052 for staff ,S1s file and 1st aid certificate, LIC501,LIC503,LIC508,LIC9052, TB, Training documents for staff, S2s file and send proof to CCL by POC date-10/05/23.Additionaly, Licensee will ensure that all required paperwork will be completed for all staff's files per this regulation and will send statement of understanding to CCL by POC date-10/05/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023


LIC809 (FAS) - (06/04)
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