198602067-4-29-2024-28-AS-KRAZ-D4SRAC-20240429125056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602067
Report Date: 04/29/2024
Date Signed: 04/29/2024 12:51:23 PM

Document Has Been Signed on 04/29/2024 12:51 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:	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:	04/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:43 AM
MET WITH:	Caregiver Venus Calzado		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 04/29/2024. LPA was met by Caregiver Venus Calzado and explained the purpose of the visit. Administrator Michelle Aguirre arrived shortly after to assist with the visit. Facility is licensed to residents 60 years old and above. The facility is approved for 6 non-ambulatory. The facility may retain four (4) hospice residents. LPA requested and obtained a copy of Personnel Report (LIC 500), Resident Roster (LIC 9020), copy of liability insurance and updated Infection Control plan. LPA Ramirez observe video surveillance in common areas only.

LPA OBSERVATIONS: The facility is a single-story building in a residential area with three (3) resident bedrooms, two (2) shared bathrooms, kitchen, dining room, living room, den/tv room, front yard, backyard and attached garage.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables.

Dining Room/Living room/Den/TV room: Dining room was observed to be clean and contained table and 6 chairs. Living room area has plenty of seating for residents and guests. Den/Tv room was observed to be clean and contained plenty of seating. LPA Ramirez three (3) residents sitting in this area during inspection.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Resident Rooms 1 - 3: All resident bedrooms are currently shared. All contained the required furnishings, linens and were observed to be clean.

See 809-C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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: HOUSE OF GRACE LLC	FACILITY NUMBER: 198602067
	VISIT DATE: 04/29/2024

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Centrally Stored Medications: Was observed to inaccessible to six (6) out of six (6) residents in care. Medications are stored in facility medications cabinet, near kitchen area.

Emergency Drills/Emergency Disaster Plan/First Aid Kit: LPA Ramirez observed Emergency & Disaster Plan (LIC 610E) during inspection. Last two (2) fire drills were conducted on 03/01/24 and 02/20/24. LPA Ramirez observed a First Aid kit in facility hallway.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for two (2) staff. LPA Ramirez observed Administrator’s certificate for Michelle Aguirre with an expiration date of 08/28/2024. First Aid & CPR Certificate, Fingerprint Clearance/ Exemptions, Personnel Record/Job Application, Health Screening, Employee Rights, TB Test, and Initial/Annual Training Verification were observed for two (2) out of two (2) personnel records observed.

Resident Records: Six (6) resident files were reviewed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form were observed.

Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan.

No deficiencies were cited during this inspection. Exit interview was conducted and a copy if this report was provided via email due to printer issues.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

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