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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603221
Report Date: 01/18/2024
Date Signed: 01/18/2024 10:37:12 AM

Document Has Been Signed on 01/18/2024 10:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SAVING GRACE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198603221
ADMINISTRATOR:DANTZLER, GLENDA JFACILITY TYPE:
735
ADDRESS:2023 CULLIVAN STREETTELEPHONE:
(323) 770-4501
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 4CENSUS: 2DATE:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Glenda J. DantzlerTIME COMPLETED:
11:00 AM
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On 01/18/2024 at 8:00 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection.

LPA met with the Administrator Glenda J. Dantzler. LPA explained the purpose of today’s visit. The Adult Residential Facilities (ARF) facility is licensed to operate to serve Developmentally Disabled Adults for four (4) ambulatory ages 18 through 59 years of age. LPA observed there are two (2) Westside Regional Center consumers at the time visit. LPA toured the physical plant. The requested capacity is for 4 clients, ambulatory. The Adult Residential Facilities (ARF) facility is a three (3)-bedroom, one (1)-bathroom, single story house with a two (2)-car de-attached garage. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a back yard with a covered patio as well as a shaded area. The shaded area contained a table and four (4) chairs. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. All bedrooms are for four (4) ambulatory clients. Bedroom one (#1) has two beds, two chairs, one-night stand, overhead lighting and one (1) dresser with four drawers. Bedroom two (#2) has 1 one bed, one bedside table, overhead lighting, and one dresser with four (4) drawers. Bedroom #3 has one bed, one bedside table, one dresser with five (5) drawers. All drawers comply with the requirement of 8 cubic feet of space. There were no designated staff bedrooms observed.



Bathroom has a working toilet, wash basins and shower.

LIC-809 continued on next page.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SAVING GRACE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603221
VISIT DATE: 01/18/2024
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Water in bathroom was measured at 121 degrees F. LPA observed adequate lighting in hallway leading to bathroom. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hall closet. The telephone system (323-305-3822) works and has a land line which was called by LPA and is operational. Emergency Disaster Plan and "See something, say something, Let Us Know" posted & readily available for review on the wall between the living room and kitchen. Menu available for review on posting board next to monthly activity plan. Two fully charged fire extinguishers were found in the facility mounted on wall of kitchen and one in the hallway leading to the bedrooms. Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet in kitchen.
Food supply was adequately stored in kitchen refrigerator and cabinets and consists of the following: A variety of Fresh and Canned fruit, vegetable, and meat food items.

Six (6) smoke detectors are hardwired and interconnected. Two (2) carbon monoxide detectors are present in the facility. Stove burners, oven, microwave, dish washer, washer, and dryer working. There is one (1) refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage. The residence is equipped with central heat. Locked/stored in the storage closet located in the hallway. A review of Medication Records Administration (MAR) and Fire Drills were observed to be maintained in order and accurate (two (2) clients). The last fire drill was on 10/19/2023. LPA observed two (2) client medication records and first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze which are stored in locked kitchen cabinet, available for staff use but inaccessible to clients. LPA observed and reviewed cash resources of two (2) clients and holds a surety bond for $1,000.00. Cash resources are locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in the garage, section has been inspected along with the available records present. A comfortable temperature of 70 degrees was maintained in the facility.The facility has board games, books, and other recreational materials for the client's use. Activity board is posted on the wall in the kitchen. LPA did not observe any pet or bodies of water at the facility. Fire Clearance was approved on 9/16/2019 for 4 ambulatory clients with no special instructions. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. LIC-809 continued on next page.No deficiencies were cited during this inspection visit.
There were one (1) Advisory Notes—Technical Assistance provided during today inspection visit.
An exit interview was conducted, and a copy of this report was provided to Glenda J. Dantzler, Administrator..
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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