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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602863
Report Date: 12/29/2025
Date Signed: 12/29/2025 12:48:41 PM

Document Has Been Signed on 12/29/2025 12:48 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HOUSE OF GRACE 2FACILITY NUMBER:
198602863
ADMINISTRATOR/
DIRECTOR:		AGUIRRE, MICHELLEFACILITY TYPE:
740
ADDRESS:2815 MESA DRIVETELEPHONE:
(626) 716-1033
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 6DATE:
12/29/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Rebecca Sinclair - Co-Administrator
Vanessa Arbis - Caregiver		TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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) Bennette Pena conducted a subsequent unannounced Required-1 year visit for annual continuation. LPA met with Vanessa Arbis, Caregiver and Tito Riobuya, Caregiver and explained the purpose of the visit. The administrator, Michelle Aguirre was called on the phone and was not able to meet with LPA during the visit. Shortly after, Co-Administrator Rebecca Sinclair arrived to assist. LPA continued with the inspection using the Compliance and Regulatory Enforcement (CARE) tool and observed the following:

Staffing: A total of (4) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Current Administrator's certificate is valid and expires on 08/28/2026.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (2) staff files. Proof of staff training, health clearance, and vaccinations are current. Dementia care is part of training for direct care staff.
Resident Rights-Information: Resident rights are posted. Facility provides internet service and phone to the residents.
Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities. Resident Records-Incident Reports: LPA reviewed (6) Resident files. Residents files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment,Resident Personal Propert y and Residents Personal Rights observed.
*****REPORT CONTINUED ON LIC809-C*****
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2025
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 8
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOUSE OF GRACE 2
FACILITY NUMBER: 198602863
VISIT DATE: 12/29/2025
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
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan which is posted. Facility conducts emergency drill (earthquake & fire) at least quarterly.
Residents with SHN: Facility accepts and retains residents with dementia. Facility has sufficient space to permit residents with dementia to wander freely and safely. Co-Administrator and staff stated that there is no night shift staff on duty to supervise residents with dementia. All (6) residents have hospital bed rails with authorizations on file. (2) of (6) residents are under hospice care. Resident #3 (R3) and Resident #5 (R5's) file physician’s report has a Dementia diagnosis that are over a year old.

Deficiencies cited on LIC 809D and Technical Violation issued. Exit interview, appeals rights and a copy of this report were provided to Rebecca Sinclair, Co-Administrator.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 12/29/2025 12:48 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/29/2025 at 12:14 PM
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: HOUSE OF GRACE 2
FACILITY NUMBER: 198602863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that hot water temperature readings were 140 deg F in bathroom #2 and 133.8 deg F in bathroom #3 during the inspection conducted on 12/18/2025 which are not within the required 105 - 120 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2025
Plan of Correction
1
2
3
4
DEFICIENCY CLEARED DURING THE ANNUAL CONTINUATION. At 11:56am, LPA re-checked the hot water temperature in Bathrooms #2-#3 and read at 11 deg F and 112.6 deg F respectively, which met the Title 22 Regulations requirement.
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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 12/29/2025 12:48 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/29/2025 at 12:14 PM
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: HOUSE OF GRACE 2
FACILITY NUMBER: 198602863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that LPA observed part of the garage is being used as a sleeping room for staff which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 12/29/2025
Plan of Correction
1
2
3
4
DEFICIENCY CLEARED. Administrator sent a photo of the garage without the beds on 12/19/2025. LPA confirmed that the garage has been cleared of the beds during the annual continuation on 12/29/2025.
Deficiency Dismissed
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in that the facility does not maintain a record to document medication administration of each residen which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 12/29/2025
Plan of Correction
1
2
3
4
DEFICIENCY CLEARED. During the annual continuation visit, staff provided the Medication Administration Records (MARs) of the residents which have been documented properly by the dtaff.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2025


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 12/29/2025 12:48 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/29/2025 at 12:14 PM
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: HOUSE OF GRACE 2
FACILITY NUMBER: 198602863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87705(b)(2)
Care of Persons with Dementia
(b) Licensees shall be responsible for the following: (2)For facilities with fewer than 16 residents, ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal, or observation, to require awake night supervision. This requirement is in addition to requirements specified in Section 87415, Night Supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, record review, the licensee did not comply with the section cited above in that the co-Administrator and staff stated/confirmed that there is no night shift staff on duty to supervise residents with dementia which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2026
Plan of Correction
1
2
3
4
Administrator/Licensee shall ensure tha there is at least one night staff person awake and on duty to supervise residents with dementia. Administrator to submit an updated personnel report/LIC500 indicating night shift staff to CCL/LPA by POC due date.
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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 12/29/2025 12:48 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/29/2025 at 12:27 PM
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: HOUSE OF GRACE 2
FACILITY NUMBER: 198602863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87705(c)(5)
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, Resident #3 (R3) and Resident #5 (R5’s) file physician’s reports have a Dementia diagnosis that are over a year old which poses a potential health, safety, or personal rights risk to residents in care.
POC Due Date: 01/12/2026
Plan of Correction
1
2
3
4
The facility will ensure that Resident #3 (R3) and Resident #5 (R5’s) physician’s report is updated and send the updated Medical assessment/Physician's report to CCL/LPA by POC due date.

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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2025


LIC809 (FAS) - (06/04)
Page: 8 of 8