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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603109
Report Date: 05/11/2023
Date Signed: 05/11/2023 01:09:07 PM


Document Has Been Signed on 05/11/2023 01:09 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:GRACE BLOSSOM CAREFACILITY NUMBER:
198603109
ADMINISTRATOR:IKPEAMAEZE, LILIANFACILITY TYPE:
740
ADDRESS:20430 HARVEST AVETELEPHONE:
(951) 816-1077
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY:6CENSUS: 5DATE:
05/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Lilian Ikpeamaeze - Administrator TIME COMPLETED:
01:23 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit using the CARE Tool. LPA met with Lilian Ikpeamaeze ( Administrator) and explained the reason for the visit. The facility is licensed to serve 6 non-ambulatory residents age 60 and above of which 1 may be bedridden. Facility has a hospice waiver for 4 residents. The facility is operating within the scope of its license.

A tour of the single-story facility included: living room, kitchen, dining area, activity area, 4 resident bedrooms, 1 administrator office, 1 staff bathroom, 1 resident bathroom, and attached garage. LPA and Lilian Ikpeamaeze toured the facility and the following was observed: the front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. Auditory devices were seen on exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in both bathrooms and measured at 109 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. There are 2 fire extinguishers located in the kitchen and living room which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps, cleaning supplies and toxins are kept locked under the kitchen sink and are inaccessible to residents. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. First Aid kit was fully stocked with current manual and it is kept locked in the administrator office. Residents and staff files are centrally stored in the administrator office. Residents medication are centrally stored in locked cabinets in the kitchen. LPA reviewed medication for all 5 residents and observed that medications are documented properly and given as prescribed. (Continued to LIC 809C).
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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: GRACE BLOSSOM CARE
FACILITY NUMBER: 198603109
VISIT DATE: 05/11/2023
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LPA reviewed all 5 resident files and 5 staff files. LPA observed administrator certificate for Lilian Ikpeamaeze – 6049496740 with an expiration date of 08/26/2024. LPA interviewed 2 residents and 3 staff.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report were provided.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC809 (FAS) - (06/04)
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