198603617-1-20-2023-28-AS-KRAZ-CN9V4M-20230120150635

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603617
Report Date: 01/20/2023
Date Signed: 01/20/2023 03:06:48 PM

Document Has Been Signed on 01/20/2023 03:06 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 3		FACILITY NUMBER:	198603617
ADMINISTRATOR:	SINCLAIR, REBECCA		FACILITY TYPE:	740
ADDRESS:	2178 URSINUS CIRCLE		TELEPHONE:	(626) 716-1033
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 0	DATE:	01/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:43 PM
MET WITH:	Michelle Aguirre		TIME COMPLETED:	03:20 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a announced visit to the facility for the purpose of conducting a Pre-Licensing inspection. LPA met with applicants Michelle Aguirre and Rebecca Sinclair and explained the purpose of the visit. An application was submitted on to CCLD on 09/23/2022, for initial license for a Residential Care Facility for the Elderly to serve residents of 60 years and older. The requested capacity is for six (6) non-ambulatory residents and have an approved hospice waiver for four (4).

The facility is a home located in a residential area, which consists of four (4) bedrooms, two (2) bathrooms, kitchen, dining room, activities area, living room, back patio with shade, and attached three (3) car garage that will house a staff office. All passageways, walkways, and ramps were observed to be free from obstruction, debris, and hazards. LPA observed COVID-19 signage promoting cough/sneeze etiquette. The living room has a fireplace with a rod-iron cover, making it inaccessible to residents. Resident records will be centrally stored in a locked cabinet in dining room area. Medications, 2 First Aid Kits, PPE’s, hygiene products, hand soaps, hand sanitizer, sharps and knives will be centrally stored in a locked hallway closet. Disinfection solutions and cleaning products are housed in the garage which will be inaccessible to residents. Kitchen appliances were observed to be clean and were operational. Water temperature in kitchen sink was measure at 105 degrees F which meets Title 22 California Code of Regulations.

Continued on LIC809-C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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: HOUSE OF GRACE 3	FACILITY NUMBER: 198603617
	VISIT DATE: 01/20/2023

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Food supply was observed to be sufficient. LPA observed flatware, cups, and utensils to be sufficient and in good repair for resident use. Fire extinguisher located next to kitchen was observed to be fully charged. Bedrooms # 1, 2, 3 are all resident bedrooms and were observed to contain the required furniture, linen, and have sufficient storage space and adequate lighting. Bedroom # 4 is for live in staff and contains bathroom #2. Residents will not have access to bedroom #4 and bathroom #2. Resident bathroom #1 was observed to have operating toilet, wash basin, and shower had the required grab bars. Water temperature in resident bathroom #1 was measured at 106.8 degrees F which meets Title 22 California Code of Regulations. Soap and paper towels were observed in resident bathroom. LPA observed signage promoting hand washing. Sufficient additional linens, and bath towels were observed in hallway closet. Fire extinguisher located near hallway was observed to be fully charged. The smoke/carbon monoxide detectors were tested and observed to be inter-connected and fully operational. Fire Clearance was approved on 11/29/22. The attached garage will remain locked and inaccessible to residents in care. In the garage are the washer and dryer, operational and in good repair. Laundry washing supplies are maintained on a rack above the washer and dryer, inaccessible.

LPA Ramirez has cleared the physical plant.

An exit interview was conducted with applicants and a copy of this report was furnished. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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