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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004711
Report Date: 09/09/2022
Date Signed: 09/09/2022 01:15:12 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/09/2022 01:15 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 RIVERBANKFACILITY NUMBER:
507004711
ADMINISTRATOR:MATIS, VOICAFACILITY TYPE:
740
ADDRESS:5708 AMBERWOOD LANETELEPHONE:
(209) 869-4859
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 4CENSUS: 4DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Rosalinda Ortega and Voica MatisTIME COMPLETED:
01:30 PM
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On 9/9/22 at 9:50am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with care provider Rosalinda Ortega. Licensee Voica Matis arrived at the facility shortly after. LPA Jensen explained the purpose of today's visit to Rosalinda Ortega and Voica Matis.

The facility is a single story structure with a single designated entry point. The entry point has a sign in sheet and is equipped for COVID screening. The facility has 3 bedrooms, one of which is double occupancy and 2 single occupancy rooms. The bedrooms were observed to be adequately furnished. There was an adequate supply of linen on hand. The lighting throughout the facility was adequate. The thermostat was set at 76 degrees for the comfort of the residents. There is emergency lighting on hand. There are two 1st aid kits at the facility complete with scissors, tweezers, thermometer, various wound dressings and 1st aid manual. The bathrooms were observed to be sanitary and contained cleaning supplies that are locked in a cabinet under the sink. The temperature of the water in the bathroom measured at 124 degrees. There is a Caution-hot water sign posted. The fire extinguishers were last serviced in June of 2022 and are in compliance. The carbon monoxide and fire detectors were tested and are in good repair.

The kitchen was observed to be sanitary. There was a 2 day supply of perishable food and 7 day supply of non-perishable food on hand. There was no expired food observed and items were labeled with expiration dates. Knives are stored in the kitchen in a locked drawer and are inaccessible to residents. Medications are stored in the kitchen in a locked cabinet and inaccessible to residents. Two sets of scissors were observed in an unlocked drawer in the kitchen under the microwave. A locked safe is stored in the refrigerator for medications that are temperature controlled.

Continued on LIC 809C...
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 RIVERBANK
FACILITY NUMBER: 507004711
VISIT DATE: 09/09/2022
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Continued from LIC 809...
The facility was free of odor and free of clutter. The carpeting in the bedrooms was observed to be stained in high traffic areas. The corners of the walls and walls in bathrooms were observed to be scraped from friction. The window screens were observed to be in good repair. The dining room and living room were sanitary and furnished sufficiently to accommodate the residents needs.

The front and back yards are landscaped and well maintained. The backyard has a large concrete patio with outdoor furniture to accommodate all residents. The backyard patio also serves as the activity area. There are grapes growing along the backyard fence that are in season which the residents may consume if they choose. The exit path in the backyard was observed to be obstructed with an inoperable microwave, mattress, a glass shower door and frame and other debris.

4 of 4 resident files were reviewed. 1 staff file was reviewed. All staff present at the facility had criminal background clearance and were associated to the facility. The LIC 610 was reviewed and determined to be in compliance. The facility had the postings throughout including but not limited Resident Rights, COVID prevention, Ombudsman and See Something, Say Something.

Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6.

An exit interview was conducted with staff member Rosalinda Ortega with permission of the licensee. A copy of this report along with appeal rights were given to Rosalinda Ortega.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2022 01:15 PM - It Cannot Be Edited


Created By: Maja Jensen On 09/09/2022 at 12:43 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 RIVERBANK
FACILITY NUMBER: 507004711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2022
Section Cited
CCR
87705(f)(1)

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(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met as evidenced by:
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The scissors were immediately relocated to a locked cabinet in the presence of the LPA. No further plan of correction is required at this time.
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Based on LPA's observation of two sets of scissors in an unlocked drawer located in the kitchen under the microwave. This poses an immediate risk to the health, safety and personal rights of residents in care.
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Type B
10/07/2022
Section Cited
CCR87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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The licensee agrees to have the carpets cleaned and the debris removed from the backyard pathway to the exit by the POC due date. The licensee will email photos as proof of correction to maja.jensen@dss.ca.gov. The wall scuffs will addressed at a later date during an anticipated remodel.
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Based on LPA's observation of the stained carpets and obstruction in teh backyard pathway including inoperable appliances, a mattress and shower glass door and frame plus various debris. This poses a potential health, safety and personal rights 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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


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