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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603555
Report Date: 05/30/2023
Date Signed: 05/30/2023 02:48:18 PM


Document Has Been Signed on 05/30/2023 02:48 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:CIRCLE OF GRACE, INC.FACILITY NUMBER:
198603555
ADMINISTRATOR:KHACHATRYAN, ANNAFACILITY TYPE:
740
ADDRESS:7157 HIDDEN PINE DRTELEPHONE:
(818) 425-6797
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:6CENSUS: 6DATE:
05/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Anna Khachatryan, AdministratorTIME COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Caregiver Diana Castellanos. Administrator Anna Khachatryan arrived shortly after. There are currently 5 elderly residents 60 years and older and 1 resident under age 59 residing in the facility. Four (4) residents are receiving hospice care, five (5) residents have Dementia, and one (1) resident is enrolled in home health.

The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The Infection Control Plan and Covid-19 Mitigation Plan/MonkeyPox plans were reviewed.


Operational Requirements:
  • Facility has a current Plan of Operation at main headquarters.
  • The facility has a Dementia Waiver in place. A Hospice Waiver for 2 is approved. A hospice waiver increase is pending approval.
  • A fire clearance for 6 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room #4.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 5/30/2024.
  • A surety bond is not applicable. Resident monies are not handled.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CIRCLE OF GRACE, INC.
FACILITY NUMBER: 198603555
VISIT DATE: 05/30/2023
NARRATIVE
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Physical Plant/Environment Safety:
  • The facility is a single-story home located in a residential area consisting of six (6) bedrooms, two (2) full bathrooms, kitchen, dining room, living room, laundry room, rear shaded patio area, and attached garage.
  • Per Fire Marshall the facility was required to install fire doors. They were tested and observed operational.

  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents.
  • Fire clearance was granted on 5/4/2022 for five (5) non-ambulatory residents and one (1) bedridden resident.
  • The facility has two (2) fully charged fire extinguishers. Smoke and carbon monoxide detectors are operational.
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Water temperature ranged between 101.6 - 109.9 degrees Fahrenheit.
  • The exterior north side gate door was locked from the interior facility grounds. There is no fire clearance approved for locked perimeter fence gate. Citation was issued.

Staffing:
  • A total of four (4) caregiver staff provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificates expired 3/8/2023. Administrator stated the renewal documents were submitted to the recertification unit but an Administrator Certificate has not been received yet. Proof of document submittal was provided.
  • Four (4) personnel files/training were reviewed. Staff training, health clearance, criminal background clearance and 1st Aid/CPR training was verified.

***narrative continues next page***
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: CIRCLE OF GRACE, INC.
FACILITY NUMBER: 198603555
VISIT DATE: 05/30/2023
NARRATIVE
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Resident Records/Incident Reports:
  • A total of four (4) resident files were reviewed. They included admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment/Appraisals, hospice care plans, and emergency information.
  • RCFE complaint poster and Personal rights were observed posted in the facility entrance area.

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • Indoor and outdoor activities are performed daily.
  • The facility does not have a Resident Council.

Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
  • Physician order for modified diet is on file.
  • Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:
  • Four (4) centrally stored 30-day supply of medications were reviewed.
  • Medical and dental transportation is provided by family members.

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place.
  • The last quarterly fire/emergency drill was completed on 2/15/2023.


See next page
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: CIRCLE OF GRACE, INC.
FACILITY NUMBER: 198603555
VISIT DATE: 05/30/2023
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Residents with Special Health Needs:
  • One (1) resident receives home health services. Four (4) residents receive hospice care.
  • Postural support physician orders are on file.
  • Half and full bed rails for mobility assistance were observed in all resident beds. Residents (R1 & R2) have full bed rails but are not enrolled in hospice. *** Only hospice residents may have full bed rails. Citation was issued.
  • Appraisals were observed in resident files.
  • No residents have prohibited health conditions.


Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Administrator Anna Khachatryan. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/30/2023 02:48 PM - It Cannot Be Edited

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: CIRCLE OF GRACE, INC.
FACILITY NUMBER: 198603555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that R1 had a full length bed rail, and R2's bed had had two half rails converting it into a full rail. The residents are not enrolled in hospice; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2023
Plan of Correction
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Administrator agreed to remove the full bed rails from R1 & R2's bed, and obtain a physician order for half rails. Submit pictures of resident beds and copie of the physician orders by tomorrow.
Type A
Section Cited
CCR
87705(l)(2)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the north side exterior gate door had a lock on the gate latch, whick poses an immediate health, safety or personal rights risk to persons in care. Picture was taken.
POC Due Date: 05/30/2023
Plan of Correction
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Locks shall be removed from all exterior exit doors. Staff removed lock during the visit. ***Cleared during the visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5