198201903-5-17-2023-11-AS-ARID-CRX228-20230517170019

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198201903
Report Date: 05/17/2023
Date Signed: 05/17/2023 05:00:27 PM

Document Has Been Signed on 05/17/2023 05:00 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 CORPORATION		FACILITY NUMBER:	198201903
ADMINISTRATOR:	AARON, RUTH		FACILITY TYPE:	735
ADDRESS:	2417 WEST 154TH STREET		TELEPHONE:	(310) 537-2018
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY: 6		CENSUS: 2	DATE:	05/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Stephanie wright		TIME COMPLETED:	05:10 PM

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On 05/17/23, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with administrator Stephanie Wright, and explained the purpose of today’s visit. This facility is a level 4I home, licensed to serve 6 Non-Ambulatory Developmentally Disabled adults ages 18 to 59 years old. Vendorized with the South Central Los Angeles Regional Center.
LPA and Administrator toured the entire facility inside and outside grounds. The home is in a residential neighborhood and consists of (5) client bedrooms, (2) bathrooms, living room, den, kitchen and dining area, and patio with permanent cover. The facility is a single-story structure located in a residential neighborhood. The residential home has the following areas: 5 bedrooms, 2 bathrooms, living/ dining area, kitchen, den, and backyard patio.

LPA and Administrator toured the physical plant. There were no bodies of water outside. There were potential hazard and debris of obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident 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. The hot water temperature measured 108.5 degrees Fahrenheit. A comfortable temperature of 75 degrees Fahrenheit was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. The facility fire extinguisher is charged, and smoke detectors and carbon monoxide are operable. A review of Medication Administration Records (MAR) was maintained in order and accurate.

Evaluation Report Continued on LIC 809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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: 198201903
	VISIT DATE: 05/17/2023

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols 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. A review of staff and resident temperature logs were reviewed. deficiencies were cited during this inspection visit.

According to the California Code of Regulations Title 22, LPA did observed a deficiency, therefore a type B citation was issue.

An exit interview was conducted. A copy and appeal right of this report were provided to Administrator Stephanie Wright.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/17/2023 05:00 PM - It Cannot Be Edited

Created By: Antonine Richard On 05/17/2023 at 04:38 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: 198201903
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(c)

Building and Grounds

(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,interview , the licensee did not comply with the section cited above in object, broken glass which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	The administrator Stephanie Wright will ensure the backyard is free of hazards and debris all the time. Licensee will submit pictures of the backyard free of hazards and debris, to LPA Antonine.Richard@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Antonine Richard

LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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