<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507206802
Report Date: 04/29/2022
Date Signed: 04/29/2022 04:16:07 PM

Document Has Been Signed on 04/29/2022 04:16 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 OAKDALE 2FACILITY NUMBER:
507206802
ADMINISTRATOR:MATIS, VOICAFACILITY TYPE:
740
ADDRESS:1188 DEITZ CIRCLETELEPHONE:
(209) 595-1028
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 6CENSUS: 6DATE:
04/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Rainilda ClavanoTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Victoria Brown arrived unannounced 4/29/22 at 2:20pm on a subsequent complaint visit. 27-AS-20220419085726

LPA was met by Rainilda Clavano, Caregiver and stated the purpose of todays visit.

During the complaint investigation, LPA observed the Medication Administration Record (MAR) which indicated the medications for 8am and 8pm were given for the dates of 4/29/22, 4/30/22, and 5/1/22.

LPA also observed the Tablets-Capsules-Ampules Log was missing signatures and/or initials for 4/29/22 which should indicate that medications were passed.

Staff # 1 (S1) stated that it was busy and it is usually completed at night.

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.
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)
Page: 1 of 2
Document Has Been Signed on 04/29/2022 04:16 PM - It Cannot Be Edited


Created By: Victoria Brown On 04/29/2022 at 03:43 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 OAKDALE 2
FACILITY NUMBER: 507206802

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2022
Section Cited
CCR
87465(h)(5)

1
2
3
4
5
6
7
Incidental Medical and Dental Care
The following requirements shall apply to medications which are centrally stored:Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
1
2
3
4
5
6
7
Licensee shall submit a plan to conduct an in-service for staff regarding medication processes. The in-service shall be completed by 5/6/22 with proof faxed to CCL.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: LPA obtained information that the medications were transferred from the original container.
Based on the Licensee did not ensure the medication was provided to the person it was prescribed for. This possess an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
04/30/2022
Section Cited
CCR87465(d)(3)

1
2
3
4
5
6
7
Incidental Medical and Dental Care
If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met:The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.
1
2
3
4
5
6
7
Licensee shall submit a plan to conduct an in-service for staff regarding medication and procedures. The in-service shall be completed by 5/6/22 with proof faxed to CCL.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: LPA observed that the medication records were completed days in advance.
Based on the Licensee did not ensure the medication record is maintained appropriately This possess an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
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)
Page: 2 of 2