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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201837
Report Date: 02/05/2025
Date Signed: 02/05/2025 06:44:36 PM

Document Has Been Signed on 02/05/2025 06:44 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:GRACE CARE CORPORATIONFACILITY NUMBER:
198201837
ADMINISTRATOR/
DIRECTOR:		KATHY MARSHALLFACILITY TYPE:
735
ADDRESS:116 E. 189TH STREETTELEPHONE:
(310) 527-0170
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 6CENSUS: 4DATE:
02/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:56 PM
MET WITH:Christopher Aaron TIME VISIT/
INSPECTION COMPLETED:
04:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Vice President Christopher Aaron, 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 Dabuet and staff toured the physical plant. There are no bodies of water 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 at 105.0 degree F. 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 extinguishers were charged, smoke detectors and Carbon Monoxide were operable. The last Fire Drill was conducted on 12/23/24.

(Evaluation Report LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 198201837
VISIT DATE: 02/05/2025
NARRATIVE
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During the visit, LPA Dabuet observed the facility infection control practices. LPA observed 30-day supply of Personal Protective Equipment (PPE).

An audit of clients #1-#4 (C1-C4) service files and staff #1-#4 (S1-S4) personnel files revealed to be complete. An audit of the resident's P&I is maintained in order and complete. The facility has the current administrator's certification on file for Stephanie Aaron valid date through 09/20/25 #7005637735.

DEFICIENCIES:
  • Staff #1 had an expired First Aid/CPR certificate.
  • Staff #5 did not have Criminal Clearance Background

According to the California Code of Regulations (Title 22, Division 6, Chapter 1), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Christopher Aaron and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/05/2025 06:44 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 02/05/2025 at 03:30 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 198201837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section. LPA identified Staff #5 did not have Criminal Clearance and has been employed since October 2024. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Licensee will adhere to Title 22 Regulations 80019(e) and ensure that all staff prior to working must have Criminal Clearance Background processed. Licensee will immediately remove Staff #5 from employment/schedule until the Staff #5 is Live Scan for Criminal Clearance Background. POC correction must be sent to LPA Dabuet via email: ernand.dabuet@dss.ca.gov
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/05/2025 06:44 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 02/05/2025 at 03:31 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 198201837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA identified Staff #1 did not have a current First Aid/CPR certificate. The certificate expired in 2023 and has been working as DSP. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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Licensee will adhere to Title 22 80075 and ensure that all staff with direct access with clients in care must have a valid/current First Aid/CPR certificate. Staff #1 will require to recertify for First Aid/CPR with proof of certification by POC date. POC must be sent to ernand.dabuet@dss.ca.gov
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
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