198602067-6-17-2022-28-AS-BTAO-CFGVGU-20220617162604

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602067
Report Date: 06/17/2022
Date Signed: 06/17/2022 04:26:10 PM

Document Has Been Signed on 06/17/2022 04:26 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	HOUSE OF GRACE LLC		FACILITY NUMBER:	198602067
ADMINISTRATOR:	MICHELLE AGUIRRE		FACILITY TYPE:	740
ADDRESS:	618 RIDGEFIELD DRIVE		TELEPHONE:	(626) 716-1033
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 6	DATE:	06/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Rebacca Sinclair, administrator		TIME COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Tao conducted an unannounced annual required visit at the facility. LPA met with Administrator, Rebecca Sinclair, who assisted with the visit. The purpose of the visit was discussed. Facility is licensed to serve six (6) non-ambulatory, age 60 and above, approved for four (4) hospice waivers. Currently, three residents on hospice. Annual licensing fees are current.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.

The facility is a single story house located in a residential neighborhood. LPA toured the facility- physical plant, indoor and outdoor. The facility consisted of three (3) bedrooms, two (2) bathrooms, family room, living room, garage with laundry area and office, kitchen, and dining room. All residents’ bedrooms are furnished with appropriate furniture for residents’ comfort. The bathrooms are furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the residents. Smoke detectors and carbon monoxide detector are tested and operable. Fire extinguisher was fully charged. Facility maintains a comfortable temperature for residents. Auditory alarm devices to monitor exits are operable. Last disaster drill was conducted on 3/1/22. No swimming pool or bodily of water at the facility. Backyard has a shaded area for resident use. Interior and exterior space is available to permit residents to wander freely and safely.

Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Hot water temperature is 118.5 degrees Fahrenheit which is within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies are observed.

(-continued in LIC 809C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022

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: HOUSE OF GRACE LLC	FACILITY NUMBER: 198602067
	VISIT DATE: 06/17/2022

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Administrator stated there were no weapons or ammunition on premises. Mandated documents and signages are posted in common areas. Medication are centrally stored in a locked cabinet and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents.

No deficiencies were observed per California Code of Regulations, Title 22.

An exit interview was conducted. This report was discussed with Administrator. A copy of LIC 809s report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022

LIC809 (FAS) - (06/04)

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