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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800725
Report Date: 08/25/2021
Date Signed: 08/25/2021 03:03:56 PM

Document Has Been Signed on 08/25/2021 03:03 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GRACE CARE CORPORATIONFACILITY NUMBER:
197800725
ADMINISTRATOR:AARON, RUTHFACILITY TYPE:
735
ADDRESS:317 E. 189TH ST.TELEPHONE:
(310) 527-2018
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 6CENSUS: 4DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Marie Spencer, House LeadTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Jennifer Jones conducted an unannounced Required- 1 Year visit. LPA Jones met with Hose Lead, Marie Spencer and the reason for the visit was explained.

The facility is a single-story family home located in a residential neighborhood. The facility has four client bedrooms, one office, two bathrooms, living room, dining area, kitchen, laundry room and two outdoor areas with chairs. One of the outdoor areas is covered for shade. LPA Jones and staff toured the physical plant, inspected the medication area, food service, all client rooms and bathrooms. The client bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort.

The living areas are clean, bathrooms are clean and operational. Smoke and carbon monoxide detectors were operable, fire extinguisher is fully charged, medications were centrally stored properly locked in the kitchen cabinet, ample supply of perishable and nonperishable food, adequate linen and towels supply was located in the hall cabinet.. No firearms on the premises. All exit doors were in compliance, covered trash cans, and no bodies of water present. Hazardous items are inaccessible to clients, yard free of debris and hazards.

LPA observed required posting were on the wall in the dining area.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jennifer Jones
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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
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
MONTEREY PARK, CA 91754
FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 197800725
VISIT DATE: 08/25/2021
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During the visit LPA observed an up to date client file. LPA observed working staff CPR/First aid cards. LPA also observed staff vaccination cards.

During the visit, LPA observed the facility infection control practices. Upon entry, staff checked LPA's temperature. LPA observed a screening station at the entry with sanitizer and a screening log for visitors. LPA observed staff wearing mask and additional PPE supplies in the office inaccessible to the clients. Each client has their own individual room for isolation and LPA observed required postings are throughout the facility. Staff advised LPA that visitors have the option to meet inside or outside. Staff advised LPA that all clients are vaccinated and 95% of staff are also vaccinated. Staff advised LPA that the clients received their first vaccine January 13, 2021 and the second shot February 3, 2021.

No deficiencies cited: A copy of the report was giving to the staff

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jennifer Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC809 (FAS) - (06/04)
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