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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507206802
Report Date: 10/14/2025
Date Signed: 10/15/2025 06:22:20 AM

Document Has Been Signed on 10/15/2025 06:22 AM - 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 OAKDALE 2FACILITY NUMBER:
507206802
ADMINISTRATOR/
DIRECTOR:		RFACILITY TYPE:
740
ADDRESS:1188 DEITZ CIRCLETELEPHONE:
(209) 595-1028
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 6CENSUS: 5DATE:
10/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Rainileo Clavano, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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On 10/14/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required 1-year annual inspection. LPA was greeted by two Caregivers. LPA Lindstrom introduced herself and explained the purpose of the visit. A Caregiver called the Administrator, who arrived at the facility at 12:15 PM and an interview followed. The Administrator joined the LPA on a tour of the facility.

The Administrator has an Administrator’s Certificate (#7025797740) that is valid through 6/25/2027. The three Caregivers on duty at the time of the site visit had criminal background clearances and were associated with the facility. The facility had five bedrooms and three bathrooms. The current census is five residents.

The LPA toured the interior of the facility. The entire facility is clean, orderly, and odor-free. The interior is decorated and filled with natural light. The living room, dining room, and family room contained adequate seating for residents. The bedrooms were clean and contained the required furniture. The windows and window screens were intact. The bathrooms were clean and odor-free. The water temperature in the hallway bathroom was 117 degrees Fahrenheit. The bathrooms contained grab bars, a trashcan with a lid, and non-slip mats in the showers. There were extra towels, linens, and supplies in the hallways in the closet. The thermostat was set at 77 degrees Fahrenheit.

The smoke and carbon monoxide detectors were in working order. The fire extinguisher was serviced on 2/20/2025 by Touchdown. The LPA observed logs of quarterly fire drills and an emergency disaster plan that had been reviewed in 2025.

(Continued on LIC809-D)

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 7
Document Has Been Signed on 10/15/2025 06:22 AM - It Cannot Be Edited


Created By: Ellen Lindstrom On 10/14/2025 at 02:43 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACEFUL LIVING AT OAKDALE 2
FACILITY NUMBER: 507206802

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(c)(1)(A)
87458(c)(1)(A) Medical Assessment
(c) The medical assessment shall include…(1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for…(A) Communicable tuberculosis.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of resident records, the licensee did not comply with the section cited above in one out of four residents, as there was no record of a TB test for one resident, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2025
Plan of Correction
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The Licensee will arrange for the resident to have a TB test with a medical provider and submit proof of the results to the LPA at ellen.lindstrom@dss.state.fl.us.
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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Ellen Lindstrom
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2025 06:22 AM - It Cannot Be Edited


Created By: Ellen Lindstrom On 10/14/2025 at 02:53 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACEFUL LIVING AT OAKDALE 2
FACILITY NUMBER: 507206802

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411( c)(1) Personnel Requirements: (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training.. (1) Staff providing care shall receive appropriate training in first aid…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff records, the licensee did not comply with the section cited above, as one staff member had not obtained a first aid certificate yet, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
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LIcensee shall ensure that staff member otains a first aid certificate and shall submit a copy of the certificate to the LPA at ellen.lindstrom@dss.gov.ca.
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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Ellen Lindstrom
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2025


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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GRACEFUL LIVING AT OAKDALE 2
FACILITY NUMBER: 507206802
VISIT DATE: 10/14/2025
NARRATIVE
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The LPA toured the kitchen. The kitchen was clean, orderly, and odor-free. There was a two-day supply of perishable food and seven-day supply of non-perishable food in the refrigerator/freezer and kitchen cabinets. Sharps were locked in a kitchen drawer. The LPA toured the laundry room. Cleaners were locked in a cabinet in the laundry room. The LPA toured the garage and observed extra food in a refrigerator and freezer, and extra supplies in cabinets.

The LPA inspected the central medication storage. Medication was stored in a hallway closet. The LPA observed that resident medication was stored in its original containers with intact labels.A first aid kit was located in this closet that contained all the required items. The LPA reviewed the paper-based medication administration records (MAR) and found it complete and up-to-date.

The LPA inspected the grounds. The front yard had ornamental plantings and a fenced activity area with table and chairs. The backyard had two shaded areas with tables and chairs. The walkways and the exit gate were free of obstruction.

The LPA reviewed three staff files and four resident files. One resident had a medical assessment that did not include a TB test. One staff file did not include a health screening with TB test results or a first aid certificate.

The LPA requested that updated copies of the following documents be submitted to Licensing by 5:00 PM on 10/28/2025. These documents can be emailed to theLPA at ellen.lindstrom@dss.ca.gov.



(1) LIC 308 Designation of Facility Responsibility
(2) Copy of a current Administrator Certificate
(3) LIC 610 Emergency Disaster Plan
(4) Proof of Liability Insurance
(5) LIC 500 Personnel Report
(6) LIC 309 Administrative Organization

As a result of this inspection, deficiencies were cited. The facility was not in compliance with California Code of Regulations (CCR), Title 22, Division 6. The deficiencies are listed on the attached LIC 809D. Failure to correct deficiencies by the noted due date may result in the assessment of civil penalties.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2025 06:22 AM - It Cannot Be Edited


Created By: Ellen Lindstrom On 10/14/2025 at 02:59 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACEFUL LIVING AT OAKDALE 2
FACILITY NUMBER: 507206802

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review of staff files, the licensee did not comply with the section cited above, as one employee had not had a health screening with a TB test, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2025
Plan of Correction
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Licensee shall ensure that staff member obtains a health screening from a medical professional that includes a TB test and shall submit the Health Screening form to the LPA at ellen.lindstrom@dep.state.fl.us.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Ellen Lindstrom
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2025


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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GRACEFUL LIVING AT OAKDALE 2
FACILITY NUMBER: 507206802
VISIT DATE: 10/14/2025
NARRATIVE
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An exit interview was conducted with the Administrator, to whom a copy of this LIC809 report, the LIC 809D, and the appeals rights was provided. Their signature below confirms receipt of this document.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC809 (FAS) - (06/04)
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