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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201837
Report Date: 02/24/2023
Date Signed: 02/24/2023 03:36:08 PM

Document Has Been Signed on 02/24/2023 03:36 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GRACE CARE CORPORATIONFACILITY NUMBER:
198201837
ADMINISTRATOR:KATHY MARSHALLFACILITY TYPE:
735
ADDRESS:116 E. 189TH STREETTELEPHONE:
(310) 527-0170
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 6CENSUS: 4DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Stephanie Aaron (Wright) - Co-AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Co-Administrator Stephanie Aaron (Wright) (CA1), and the purpose of today’s visit was explained. The facility is licensed to serve six (6) developmentally disabled clients (age 18-59) all six (6) shall be non-ambulatory.

There are currently (4) South Central Los Angeles Regional Center clients in placement. All (4) clients are ambulatory. The facility is a two-story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 2 bathrooms, family room/dining room, kitchen, living room, outdoor shaded area, indoor and outdoor activity area, laundry room and an attached garage.

LPA and staff toured the physical plant. There are no bodies of water or firearms/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit.

The water temperature measured 135.3 F in kitchen and 128.1 F in bathroom one (1). A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed staff and residents were not wearing face coverings. LPA observed 30-day supply of Personal Protective Equipment (PPE).
See LIC809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 198201837
VISIT DATE: 02/24/2023
NARRATIVE
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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were two deficiencies observed, See LIC809-D.

During today's visit there were three technical advisories observed, See LIC9102-AN

Exit interview held. A copy of the report and appeal rights were provided to CA1, Stephanie Aaron (Wright)

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/24/2023 03:36 PM - It Cannot Be Edited


Created By: Mario Leon On 02/24/2023 at 03:05 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 198201837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA measurement and observation, the licensee did not comply with the section cited above in having the hot water higher than Title 22 regulations, at a high temperature of 135.3 F in the kitchen and 128. 128.1 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
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CA1 and LPA have agreed that CA1 will submit media evidence (photo/video), via email to MARIO.LEON@DSS.CA.GOV, of the water temperature within Title 22 regulations listed above.
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.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/24/2023 03:36 PM - It Cannot Be Edited


Created By: Mario Leon On 02/24/2023 at 03:07 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 198201837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019

80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 80019(f)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Leon's observation, the licensee did not comply with the section cited above in having staff, Shavon Aaron-Wright, associated to the facility prior to having them working in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2023
Plan of Correction
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Co-Administrator Stephanie Aaron (Wright) and LPA have agreed to have staff member associated with the facility by this evening of February 24, 2023.
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.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


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