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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600015
Report Date: 04/24/2023
Date Signed: 04/24/2023 02:33:59 PM

Document Has Been Signed on 04/24/2023 02:33 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GRACE HAVEN HOMEFACILITY NUMBER:
198600015
ADMINISTRATOR:ANTONIO SANTOSFACILITY TYPE:
735
ADDRESS:7519 LAURA STREETTELEPHONE:
(562) 928-6833
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 4CENSUS: 2DATE:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Antonio SantosTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Antonio Santos (Administrator) who assisted with the visit. The facility is licensed to serve 4 developmentally disabled adults ages 18 to 59 years old, ambulatory only. There are currently 2 clients who were placed by the Eastern Los Angeles Regional Center.
The facility is located in a residential area. A tour of the single-story facility includes: (3) bedrooms. (2) bathrooms, living room, dining room, kitchen, a den, backyard, and an attached garage. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance and also in the kitchen area.
Physical Plant & Environment Safety: There are 2 client bedrooms, 1 client bathrooms, 1 staff bedroom with 1 staff bathroom inside the room. living room, kitchen, and dining area. Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. There are no security bars or weapons on the premises. Hygiene products are readily available and stored in client restroom. The hot water temperature was tested in kitchen and client bathroom and measured at 108.6-116.2 degrees F, these are within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured locked staff bedroom and inaccessible to clients. The last Fire/Emergency Drill was conducted on 3/1/2023. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the dining area and is fully charged.
Operational Requirements: There are currently 2 ambulatory residents residing at the facility.LPA was able to interview 1 client the other was still at day program.
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GRACE HAVEN HOME
FACILITY NUMBER: 198600015
VISIT DATE: 04/24/2023
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Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Antonio Santos certificate expires on 11-15-23.
Personnel Records-Training: Staff has criminal record clearance. Staff have current CPR/first aid training and sufficient on-going training. Staff designated to administer medication has the proper annual training on file. Staff files are maintained at the facility located in a locked cabinet in the staff bedroom.
Resident Rights-Information: Residents personal rights poster is posted in the living room and is clearly visible.
Resident Records-Incident Reports: Resident files are kept locked in a cabinet in the staff bedroom and has the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet in the staff bedroom and are in their original containers. During the visit today, LPA reviewed both residents' medication no issues were observed.
Incidental Medical & Dental: All medications for clients are kept locked and inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Residents at this facility do not have restraints nor do they require the use de-escalation techniques.

LPA conducted 2 staff interviews and 1 resident interview during todays visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview held and a copy of the report was provided to administrator Antonio Santos.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC809 (FAS) - (06/04)
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