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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004710
Report Date: 04/29/2022
Date Signed: 04/29/2022 02:04:02 PM

Document Has Been Signed on 04/29/2022 02:04 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 OAKDALEFACILITY NUMBER:
507004710
ADMINISTRATOR:MATIS, VOICAFACILITY TYPE:
740
ADDRESS:580 BUCKAROO COURTTELEPHONE:
(209) 322-3629
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 6CENSUS: 5DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Rainilda ClavanoTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 4/29/22 at 12:30PM to conduct an annual inspection visit. LPA met with the caregiver Carlo Ocampo and explained the purpose of the visit. Carlo Ocampo, Caregiver contacted the Administrator regarding the visit. At this time there are 3 residents receiving hospice services. Administrator certificate expires 12/16/23 for Voica Matias. The Licensing fees are current at this time. Rainilda Clavano arrived within 15 minutes to assist with todays visit.

The facility is licensed for a capacity of 6 residents. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents during this visit. LPA observed 2-day perishables but not a supply of 7-day non-perishables during this visit.

The temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 129.3*F which is not within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, pull alarm system, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:
A copy of the signed Hospice Waiver for 2, Control of Property, Designation of Facility Responsibility (LIC308),
Personnel Report (LIC500), Theft and Loss Policy and Procedures, Transportation Procedures, Administrator Certificate-Updated, Liability Insurance, LIC 610E(3/19)

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Licensee was provided a copy of their rights (LIC9058 12/15) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.

See 809D for continuation...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/29/2022 02:04 PM - It Cannot Be Edited


Created By: Victoria Brown On 04/29/2022 at 01:30 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GRACEFUL LIVING AT OAKDALE
FACILITY NUMBER: 507004710

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited

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Maintenance and Operation
Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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This requirement is not met as evidenced by: Hot water was measured by LPA to be 129.3*F.
Based on the Licensee did not ensure the hot water temperature was between 105-120 degrees. This possess an immediate health and safety risk to residents in care.
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Type A
04/29/2022
Section Cited

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General Food Service Requirements
The following food service requirements shall apply: Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
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This requirement is not met as evidenced by: LPA observed 3 cans of vegetables and 6 cans of fruit. Based on observation and staff admitted there are no other nonperishable items in the facility. This poses an immediate health and safety risk to residents in care.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022


LIC809 (FAS) - (06/04)
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