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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601186
Report Date: 11/08/2022
Date Signed: 11/08/2022 10:51:15 AM

Document Has Been Signed on 11/08/2022 10:51 AM - 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GRACEFULL LIVINGFACILITY NUMBER:
198601186
ADMINISTRATOR:TAMARA SMALLEYFACILITY TYPE:
735
ADDRESS:1992 WILDROSE AVETELEPHONE:
(909) 461-3360
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 5DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gary Smalley TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with Administrator Gary Smalley and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed client and staff files.

Facility is a single story house and located in a residential neighborhood. Facility includes living room, formal living room, client bathroom, three clients bedrooms, kitchen, dining area, staff bathroom, two live in staff bedrooms and a attached garage. Each clients bedrooms have two beds, two chairs, two night stands, required bed linen and furniture and sufficient lighting and closet space. LPA observed in Bedroom#1 and the door was broken. The bathroom was toured and its clean, sanitary and in a good working condition. The hot water tested in the client bathroom was measured at 113.9 degrees F which is within the Title 22 regulation. The refrigerator in the kitchen and kitchen cabinet and the garage has sufficient two days perishable and seven days non perishable food. The knives and all the sharp utensils are stored in the lock box in the kitchen cabinet. All the appliances in the kitchen are working properly. The common area such as living room and dining area are clean and have required furniture. The back yard has a shaded area with tables and chairs for clients to utilized. LPA also inspected the smoke detectors and carbon monoxides and they are all working properly.

LPA reviewed all 5 clients' files to confirm emergency contact is updated. LPA also reviewed 4 staff files to confirm health screenings and fingerprint clearances and they are all updated in their personnel file. LPA inspected 5 clients medication and their MARs and they are all seemed updated and accurate.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GRACEFULL LIVING
FACILITY NUMBER: 198601186
VISIT DATE: 11/08/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in the bathroom and common area and facility is disinfected every hours, Clients' bathrooms have sufficient soap, paper towels, and signs, and PPE supplies are sufficient for 30 days.

The deficiencies cited are documented on the attached 809D.

Exit Interview conducted. A copy of the report and appeal rights will be provided to Administrator Gary Smalley.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2022 10:51 AM - It Cannot Be Edited


Created By: Christine Wong On 11/08/2022 at 10:36 AM
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRACEFULL LIVING
FACILITY NUMBER: 198601186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA observed Bedroom#1's door was broken which may have potential risk to clients in care
POC Due Date: 11/22/2022
Plan of Correction
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The administrator will ensure teh facility shall be in good repair at all times for the safety well being of clients. The administrator will repair the Bedroom#1 door and send the picture to LPA by POC due date.
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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022


LIC809 (FAS) - (06/04)
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