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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004710
Report Date: 05/04/2023
Date Signed: 05/22/2023 01:42:33 PM

Document Has Been Signed on 05/22/2023 01:42 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 AC/SC, 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: 6DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ranilda ClavanoTIME COMPLETED:
07:00 PM
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On 05/04/23, at 10:00 AM, an unannounced annual inspection was conducted by Licensing Program Analyst, (LPA) Kimberly Viarella at Graceful Living at Oakdale. LPA identified herself and the purpose of her visit to staff who contacted the Designee, Rainilda Clavano, and she arrived within 20 minutes.

Designee reported census was 6 with 2 hospice and the 2 hospice were bedridden. 4 Residents were ambulatory. The facility was licensed for 6 nonambulatory and approved for a hospice waiver of 2. They did not have a dementia program at this time. The facility was not licensed for bedridden.

The Licensee/Designated Facility Administrator, Voica Matis, Certification 6008538740, expires 1/6/2023.

The tour began in the kitchen/areas. LPAs checked the food supply and found that there were enough groceries for 2 days of perishable and 7 days of non-perishable items at this time. Knives were secured in a locked drawer and chemicals were stored in a locked cabinet and separate from the food supply. The fire extinguisher was last inspected on 06/17/22, by Stanislaus Fire.

The LPA observed the furniture, furnishings and lighting in the kitchen/family room, dinning/living room, and four bedrooms. All were in compliance. Two of the residents required oxygen and both of their bedrooms displayed the appropriate warning signs. The hot water was measured in the hallway bathroom and found to be 113 degrees, within the range of 105-120 degrees required. LPA observed that the 2 bathrooms in the house had grab bars and bath mats along with paper towels. LPA inspected the linen supply and found it to be sufficient for the residents in care.

The tour progressed to the garage. The Designee opened all of the locked cabinets. The LPA observed cleaning supplies and other toxins in one, the others contained PPE, holiday decorations and general household storage. The LPA also observed a small refrigerator for resident medications. It was not locked at this time. Continued on LIC 809C

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GRACEFUL LIVING AT OAKDALE
FACILITY NUMBER: 507004710
VISIT DATE: 05/04/2023
NARRATIVE
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The Designee led the LPA to an area being modified into a staff room. The building permit was posted. Community Care Licensing was not notified of these physical plant changes.

The inspection continued to the exterior of the house. There were no bodies of water or outbuildings present. At this time, the backyard was enclosed with a gate on one side. The area was free of debris and trip hazards. Adjacent to the front door was a small sitting area for residents to enjoy surrounded by a half-wall. All screens were intact and gutters were clear.

At the time of the inspection, medications were centralized and stored in a locked cabinet next to the refrigerator. Policies and procedures were discussed with staff in terms of dispensing and documenting the administration of resident medications. First aid kit was observed to be present and contained all of the necessary components at this time.

LPA completed a review of 5 resident files. LPA looked for the following: a signed and dated admissions agreement, a physician’s report, proof of a negative TB test, ambulatory/non-ambulatory status, ID and emergency information, an appraisal and needs service plan, a centrally stored medication destruction record, safeguards for cash resources, safeguards for property/valuables, statement of personal rights, and cash resources information. All were complete and in compliance

LPA reviewed 6 staff files. LPA looked for the following: first aid certificate, fingerprint clearances/exemptions, personnel record/job application, health screening, proof of negative TB test, medical training verification, employee rights, and criminal record statement. 2 out of 6 were missing annual training and 2 out of 6 were missing First Aid Certification.

The following forms and documents were requested to be updated and submitted to CCL via email to kimberly.viarella@dss.ca.gov by 05/19/23:

LIC 308

LIC 400

LIC 500

LIC 610

Updated Liability Insurance. (Continued on the LIC 809 C)

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
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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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GRACEFUL LIVING AT OAKDALE
FACILITY NUMBER: 507004710
VISIT DATE: 05/04/2023
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According to the California Code of Regulations (Title 22, Division 6), the LPA observed the following deficiencies listed on the LIC 809 D. Civil penalties were assessed during today's visit.

An exit interview was conducted with staff member, Rainilda Clavano . Copies of the Facility Evaluation Report and Appeal Rights were provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2023 01:42 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 05/04/2023 at 06:05 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: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview, and file review, the facility failed to obtain fire clearance for the two bedridden residents witnessed during the facility inspection.
POC Due Date: 05/09/2023
Plan of Correction
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The licensee will submit an updated facility sketch and LIC 200 to request an increase in their bedridden capacity via fire inspection. This information shall be submitted by the end of the day, 05/10/23 to CCL at kimberly.viarella@dss.ca.gov. The licensee will submit an LIC 200, LIC 999 and a check for $25.00 to Community Care Licensing to request a new Fire Clearance by 5/10/23. The forms may be emailed, the check mailed separately to the office.
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:Liza King
LICENSING EVALUATOR NAME:Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2023 01:42 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 05/04/2023 at 06:05 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: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 4 out of 4 staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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Licensee will develop a training schedule for all employees and email it to Community Care Licensing at kimberly.viarella@dss.ca.gov. by the above date. Certificates of completion will be included in the employee files at each facility for which they are associated.
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:Liza King
LICENSING EVALUATOR NAME:Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


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