Graceful Living at Village One

Type of visit: Case Management - Annual Continuation

Unannounced Annual Continuation visit conducted today by Licensing Program Analysts (LPAs) Kimberly Viarella and Charlie Yang. LPAs were met by staff member Rainilda Clavano. Delivered Annual that was conducted on 03/27/23.the state’s words, verbatim · CDSS document, Apr 10, 2023

Type of visit: Required - 1 Year

On 0/3/27/23, at 10:00 AM, an unannounced annual inspection was conducted by Licensing Program Analysts, (LPAs), Kimberly Viarella and Charlie Yang at Graceful Living at Village One in Modesto. LPAs identified themselves and the purpose of their visit to staff, Rainilda Clavano, and instructed that the facility administrator be notified of their arrival. Voica Matis, Licensee, arrived and stated that Letecia Suasin, the listed designated facility administrator, was on vacation and that she was the designated facility administrator. A brief interview with the designated facility administrator followed. Facility reported census was 5 with 2 bedridden and 2 hospice, no home health at this time. Upon inspection the LPA noted a census of 5 of which 3 were bedridden based on the LIC 602 and 3 were receiving hospice services. The facility is licensed for 6 nonambulatory and 1 bedridden and has been approved for a hospice waiver for 2 residents. Residents with dementia were observed to be in care at this facility. 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 under the sink and separate from the food supply. The fire extinguisher was last inspected on 03/06/2023, by Stanislaus Fire. The tour progressed to the backyard. An alert sounded upon exiting the building. There were no bodies of water present. LPAs observed a wooden fence enclosing the backyard. LPAs also observed a patio and walkway along the right side of the house where the garage side door was located. LPAs' observation of backyard included holes and loose boards in the fence and 2 damaged bookcases placed on their sides, along the fence side of the walkway. Behind the bookcases, and leaning against the fence, was a glass tabletop. The facility currently has no ambulatory residents, however if there were residents who enjoyed this area this would pose a safety concern. At the time of inspection, gates did not have automatic closing systems or alerts. LPAs inspected a locked shed on that side of the facility. LPAs instructed the designated facility administrator to unlock the shed and found it to contain household storage. The facility administrator led the LPAs through the side door and into the garage. LPAs observed boxes, a mattress, furniture, and medical equipment stacked to one side. LPAs observed a locked storage cabinet against the wall. LPAs instructed the designated facility administrator to unlock the storage cabinet and observed that it contained cleaning supplies. A second fire extinguisher was present in the garage (inspected 03/06/23). LPAs were then shown to a staff room that was constructed from a section of the garage. LPAs viewed the room and ensured that it was not being used by residents. A new facility sketch to reflect this physical plant update was requested. LPAs re-entered the main house through the laundry room. LPAs witnessed chemicals locked in cabinets above the washer and dryer. Two jugs of bleach were unsecured on the floor of the room. This room had a lock on the door from the kitchen-side and was inaccessible to residents. The hall bathroom was inspected next. LPAs witnessed the required grab bars and non-skid mats. LPAs measured the hot water temperature and found it to be 107 degrees Fahrenheit, within the required range of 105 to 120 degrees Fahrenheit. The linen closet contained enough bedding to be sufficient and in compliance. Resident bedrooms were inspected. Resident furniture, furnishings and lighting were found to be sufficient and met the needs of residents at this time. One resident had a private bathroom. LPAs witnessed that it possessed grab bars and non-skid mats at this time. 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. The living areas, kitchen/dining area, and all other areas intended for resident use were toured and observed to be in compliance at this time. LPAs performed file reviews for 4 residents and 4 staff members. For the resident files, LPAs 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. For the staff files, LPAs 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. (Report continues on the following page.) The following forms and documents were requested to be updated and submitted to CCL via email to kimberly.viarella@dss.ca.gov by 04/15/22: LIC 308 LIC 400 LIC 500 LIC 610 Updated Liability Insurance. 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, Nova Ybarra . Copies of the the Facility Evaluation Report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 27, 2023

The state marks this report as 14 pages; the online copy we transcribed has 13. You can request the full file from the county licensing office.

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Sarah Hurt arrived to conduct an unannounced Post Licensing inspection on this date and met with Licensee Voica Matis. There are currently 5 residents currently living at the facility. LPA inspected the physical plant with including the kitchen, bedrooms. bathrooms; living areas, and backyard area. LPA observed the facility in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed the rooms to be clean and organized with comfortable furnishings. . LPA observed the following posted in the entrance of the facility:, Resident Personal Rights, Evacuation Routes and facility license were all posted as required. See Something Say Something complaint poster is posted. LPA confirmed all residents files have required records. No deficiencies Per Title 22 Regulations were observed on this visit. Exit interview held with Licensee Voica Matis and a copy of report given at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 18, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Sarah Hurt conducted an announced visit on to the facility on 02/10/2022 at 9 a.m. for purpose of a Pre-Licensing evaluation. LPA arrived and was granted entry to the facility by Applicant Voica Matis An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Unit (CAU) on 11/30/2021 for a capacity of six non-ambulatory residents. LPA Hurt observed the following: Structure: Facility is a one story house with 4 resident bedrooms, 2 bathrooms, family / living room, dining area and kitchen. There is a 3 car garage attached in front of home. The resident bedrooms will accommodate residents' furnishings. Signal System: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms #1-4 will accommodate 6 non-ambulatory residents Bathrooms: All bathrooms have a working toilet, wash basin, and walk-in/shower. Linens and Hygiene Supplies: Adequate supply of linens is stored in hallway closet. Emergency Phone Numbers, Exit Plan, and Sample Menu: Will be posted and readily available for review in the living room. Continued on 809C... Continued from 809.. Food Service: Adequate supply of 7-day non-perishable and 2 day perishables would be stored in the kitchen and pantry. Smoke and Carbon Monoxide Detectors: Smoke and carbon monoxide alert systems were hardwired and found operational. Fire Extinguisher: 2 Fully charged and stored by the kitchen and in the garage. Fire Clearance: Approved on 01/19/2022 Appliances: Gas four burner stove with oven, refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer are located in the laundry room next to kitchen and were clean and noted to be operational. Toxins: Will be locked and stored under kitchen sink. Water Temperature: Tested and recorded at 118 degrees (within regulation) Medications, First Aid Kit & Manual: First Aid kit with guide will be stored next to kitchen. Medication will be stored and locked in kitchen. Resident and Staff Files: Records will be kept in medication cabinet. Reading Material, Games, Equipment, & Materials: The facility has materials that commensurate with their plan of operation. Continued on 809C.. . Continued from 809C.. . LPA will contact Central Applications Bureau (CAB) to advised the applicant has passed the Pre-Licensing portion of the application process. Applicant was reminded of the statute that requires notification to Licensing Program Analyst within 5 business days of admitting the first resident. This notification may be done by phone, mail, email or fax. An exit interview was conducted with Voica Matis, and a copy of this report was provided at the time of visit.the state’s words, verbatim · CDSS document, Feb 10, 2022