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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004710
Report Date: 05/02/2024
Date Signed: 05/02/2024 05:49:28 PM

Document Has Been Signed on 05/02/2024 05:49 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 OAKDALEFACILITY NUMBER:
507004710
ADMINISTRATOR/
DIRECTOR:		MATIS, VOICAFACILITY TYPE:
740
ADDRESS:580 BUCKAROO COURTTELEPHONE:
(209) 322-3629
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 6CENSUS: 6DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Voica MatisTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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On 5/2/24 at approximately 1:40 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual inspection. LPA Jensen met with Voica Matis, Resident Care Co-ordinator and explained the purpose of today's visit. The facility has fire clearance for 5 non-ambulatory and 1 bedridden as September 2023.

LPA Jensen inspected the facility grounds and observed them to be well maintained with all paths free of obstruction. The window screens were in good repair. There is outdoor furniture available for client use and and shaded areas. The backyard gate is self latching. LPA Jensen toured the interior of the facility and observed it to be sanitary and free of odor. The temperature was 75 degrees Fahrenheit which is in compliance. The facility was adequately furnished and had adequate lighting. The facility also maintains an adequate supply of linen. All medications, toxins and sharp objects were observed to be locked and inaccessible to residents in care. The facility maintains a first aid kit that is complete. The disaster plan was reviewed and is in compliance. The facility has emergency lighting, food and water on hand. Fire drills and disaster drills are conducted regularly and logged. The smoke detector and carbon monoxide detector were tested and determined to be in good working order. The fire extinguisher was last serviced in April of 2024 and is in compliance. Bathrooms have grab bars and non-slip flooring available. The baseboards in bathrooms have minor damage. The water temperature in the bathroom was measured at 106.2 degrees and is in compliance. Technical assistance was provided. LPA Jensen inspected the kitchen and observed a 2 day supply of perishable food and a 7 day supply of non-perishable food. There was no expired food observed. All required postings were observed. Night lights are available in the hallways.

LPA Jensen interviewed interviewed 2 residents and 2 staff members. LPA Jensen reviewed 5 staff files and determined them to be complete. All required staff training has been completed. LPA Jensen reviewed 3 resident files and determined them to be complete. LPA Jensen reviewed the liability insurance and determined it to be in compliance. The facility was determined to be in substantial compliance. An exit interview was conducted and a copy of this report and appeal rights were provided.


SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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