197607439-7-21-2021-11-AS-SCIS-C55UKE-20210721153900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607439
Report Date: 07/21/2021
Date Signed: 07/21/2021 03:39:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	GRACE CARE HOME		FACILITY NUMBER:	197607439
ADMINISTRATOR:	CORAZON GRACE		FACILITY TYPE:	740
ADDRESS:	13801 CATALINA AVENUE		TELEPHONE:	(310) 532-8704
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY:	6	CENSUS: 4	DATE:	07/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Corazon Grace-Licensee and administrator		TIME COMPLETED:	03:45 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	On 07/21/21, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with administrator Corazon Grace and explained the purpose of today’s visit. The facility is an RCFE licensed for six (6) non- ambulatory clients, two (2) of those bedridden. Currently, there are four clients residing in the facility, all 60 years of age or older. The facility is a one-story structure located in a residential neighborhood. It consists of the following: three (3) client rooms, one staff office, 2 bathrooms, living room, dining area, kitchen, laundry room, outdoor shaded area and attached garage. LPA and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. Water temperature in bathroom and kitchen was found to be between 110.3 and 111.1 LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Cleaning supplies and toxins, were stored in the laundry room and sharps objects are stored in locked kitchen drawers, locked and not accessible to clients. The kitchen was inspected and there is a 2-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly. Two (2) fully charged fire extinguishers were found in hallway and beside kitchen. LPA reviewed Medication Administration Record (MAR) and observed it to be maintained in order and accurate.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GRACE CARE HOME	FACILITY NUMBER: 197607439
	VISIT DATE: 07/21/2021

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During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA reviewed visitors logs, resident daily symptom logs, Fit testing and weekly testing results.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Corazon Grace.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC809 (FAS) - (06/04)

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