<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601186
Report Date: 12/11/2023
Date Signed: 12/11/2023 12:22:02 PM

Document Has Been Signed on 12/11/2023 12:22 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:GRACEFULL LIVINGFACILITY NUMBER:
198601186
ADMINISTRATOR:TAMARA SMALLEYFACILITY TYPE:
735
ADDRESS:1992 WILDROSE AVETELEPHONE:
(909) 461-3360
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 5DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Gary SmalleyTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Gary Smalley and discussed the purpose of today’s visit.

This home is approved for (4) non-ambulatory and (2) ambulatory clients. All clients residing at this home receive case management services provided by San Gabriel Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Facility has an Infection Control Plan in place.

Operational Requirements: Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms and carbon monoxide detector were tested and are operable. Fire extinguishers observed and appeared to be full. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: LPA reviewed staff files for Staff #1 (S-1) and Staff #3 (S-3). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.

Client Rights-Information: Client rights are posted and were also observed in client files.
**Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: GRACEFULL LIVING
FACILITY NUMBER: 198601186
VISIT DATE: 12/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #5 (C-5). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, House Rules, Individual Program Plan, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Cleaning supplies are kept away from the food preparation areas. The kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.



Health Related Services: The medications are centrally stored and locked inside the office/staff room. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: There are (0) clients on a restricted health plan.

Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610D/9 pages) in place.

Deficiency cited. Refer to LIC 809D.

Exit interview, appeals rights and a copy of this report was provided to Gary Smalley.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/11/2023 12:22 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 12/11/2023 at 10:31 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: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4
Acceptance and Retention Limitations (g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in (1) out of (5) files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care. Per file reviews, C-5 is the most recent client admitted that is above the age of (59).
POC Due Date: 12/29/2023
Plan of Correction
1
2
3
4
Administrator to submit required documentation (exemption) for C-5 as noted on the above regulation.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3