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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603617
Report Date: 12/07/2023
Date Signed: 12/07/2023 02:49:40 PM


Document Has Been Signed on 12/07/2023 02:49 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 3FACILITY NUMBER:
198603617
ADMINISTRATOR:VILLAR, SHELLAFACILITY TYPE:
740
ADDRESS:2178 URSINUS CIRCLETELEPHONE:
(626) 716-1033
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 6DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:04 AM
MET WITH:Caregiver- MARIO MACALINOTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 12/27/2023.
LPA was met by Caregiver MARIO MACALINO and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which six (6) may be non-ambulatory and approved hospice waiver for four (4).

LPA OBSERVATIONS: The facility is a single-story dwelling located in a residential neighborhood and consist of three (3) resident bedrooms, one (1) staff bedroom, two (2) resident bathrooms, kitchen, dining room, living room, attached garage, staff office, front yard, and backyard.

Front Yard: Front yard is well maintained, and no hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. Kitchen sink water temperature was measured at 137.2 degree F. LPA Ramirez observed chemicals and cleaning solutions, located in under kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. Kitchen appliances were observed to be clean and in working order. LPA Ramirez observed Register of Facility Clients/Residents (LIC 9020) in clear plastic sleeve and was placed on kitchen cabinet.

Dining Room/Living room/: Dining room was observed to contain one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed nearby thermostat in this area to read 77 degree F.

Linen Closet: Contained plenty linens, towels, and hygiene products.



Resident Rooms 2 - 4: LPA Ramirez inspected three (3) shared resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens. LPA Ramirez observed proper signage indicating the use of oxygen in two (2) out of the five (5) bedrooms. LPA Ramirez observed “Bedside Checklist” placed in bedrooms #3 and 4 (near entry and in plain view) that contained confidential personal and medical information for three (3) out of the six (6) residents in care.

See 809-C

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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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Document Has Been Signed on 12/07/2023 02:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: HOUSE OF GRACE 3
FACILITY NUMBER: 198603617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, water temperatures in grooming faucets were above 120 degree F, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Licensee lowered water heater during visit. Licensee will develop water log and record water temperatures for residents grooming faucets for the next 7 calender days. Licensee will send log to LPA Ramirez via email by 12/14/23. Licensee will train staff on regulation above and send proof training attendance to LPA Ramirez by 12/14/23.
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, water temperature taken in kitchen sink was measured to be 141 degrees F and was not prominetly identified by warning signs, the licensee did not comply with the section cited above in 6 out of 6 residents, staff and/or visitors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Licensee will place warning signs above taps delivering water at 125 degree F or above. Must send picture proof of sign placed above kitchen sink.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


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: 12/07/2023
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Bathroom: Bathroom#1 water temperature was measured at 141.1 degrees F. LPA Ramirez observed grab bars and non-slip mats. LPA Ramirez observed one (1) grooming razor in bathroom cabinet drawer. Bathroom#2 located in bedroom#4 was measured at 138.6 degree F.

Backyard: No hazards were observed. Plenty of shade and seating was observed.

Centrally Stored Medications: Medications were observed to be stored in facility hallway closet and inaccessible to six (6) out of six (6) residents in care.

Emergency Drills: Last documented emergency drill was conducted on October of 2023.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for three (3) staff. Documented proof of initial dementia training required within the first 4 weeks of employment was not observed for one (1) out of the three (3) personnel records reviewed.

Resident Files: Six (6) resident files were reviewed.

Liability Insurance & Infection Control Plan: LPA Ramirez obtained a copy of liability insurance. LPA Ramirez obtained a copy of Infection Control Plan.



Deficiencies and technical advisories are being cited. A copy of this report, 809-D, LIC 9120 and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/07/2023 02:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: HOUSE OF GRACE 3
FACILITY NUMBER: 198603617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
1569.625(b)(1)
1569.625 Staff training; legislative findings; contents
(b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, staff #1 training record did not document required 6 hours of dementia care with 4 weeks of employment, the licensee did not comply with the section cited above in 1 out of 3 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2023
Plan of Correction
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Licensee will certify via email plan to comply with above regulation for future staff.

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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 12/07/2023 02:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: HOUSE OF GRACE 3
FACILITY NUMBER: 198603617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(g)(1)
87705 Care of Persons with Dementia
(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items.
(1) Evidence means documentation from the resident’s physician that the resident is at risk if allowed direct access to personal grooming and hygiene items.

 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 2 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Licensee removed razor during visit. Licensee will re-train staff according to above regulation and send proof of training by 12/14/23 via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6