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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700643
Report Date: 05/14/2025
Date Signed: 05/14/2025 09:43:05 AM

Document Has Been Signed on 05/14/2025 09:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:LIVING GRACE ELDER CARE INCFACILITY NUMBER:
194700643
ADMINISTRATOR/
DIRECTOR:		BERNADETTE PEREZFACILITY TYPE:
300
ADDRESS:3241 PINE AVETELEPHONE:
(414) 499-7700
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: CENSUS: DATE:
05/14/2025
Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Bernadette PerezTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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Enforcement Analyst (EA), Mila Quinto, with the Home Care Services Branch (HCSB) conducted a case management visit due to discovery from interview with licensee and HCA file review. EA met with the licensee, Bernadette Perez.

The licensee stated HCA1 worked for the HCO from November 24, 2025, to January 4, 2025. However, record show HCA1 did not have a current home care registry.

Based on EA’s interview with the licensee and record review, the following violation is being cited in accordance with Health and Safety Code Health and Safety Code, Division 2, Chapter 13, Section 1796.43(a). See HCS 809D.

A copy of this report is emailed to the licensee.

NAME OF LICENSING PROGRAM ANALYST: Mila Quinto
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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Document Has Been Signed on 05/14/2025 09:43 AM - It Cannot Be Edited


Created By: Mila Quinto On 05/14/2025 at 09:01 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
Although this visit/inspection may have focused on the review of specific licensing requirements, the applicant/licensee must comply with all applicable requirements. The California Department of Social Services retains authority to issue citations or take disciplinary action for any deficiency.


FACILITY NAME: LIVING GRACE ELDER CARE INC
FACILITY NUMBER: 194700643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2025
Section Cited
1796.43(a)
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1796.43 Employees, Volunteers, and Affiliated Home Care Aide Requirements
(a) Home care organizations that employ affiliated home care aides shall ensure the affiliated home care aides are cleared on the home care aide registry before placing the individual in direct contact with clients. In addition, the home care organization shall do all of the following:
This requirement is not met as evidenced by:
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Based on interview and file review, HCA1 was not registered on the home registry during the time HCA1 was hired to care for a client.
This poses an immediate health and safety risk to clients 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.
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2025
LIC809 (FAS) - (06/04)
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