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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603617
Report Date: 07/30/2024
Date Signed: 07/30/2024 04:04:04 PM


Document Has Been Signed on 07/30/2024 04:04 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:
07/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Rebecca SinclairTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 07/30/2024. LPA Ramirez was greeted by Caregiver Marianaila Macalino and explained the purpose of the visit. Back up Administrator Rebecca Sinclair arrived shortly after. Case Management-Deficiencies findings:

On 7/23/2024, LPA Vaid conducted a subsequent complaint investigation, and it was revealed to LPA Vaid that the facility was experiencing an active epidemic outbreak. Per Title 22 , Division 6, Chapter 8, Article 04, Operating Requirements, 87211(a)(1)(2) Reporting Requirements- (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:


(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.
(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
(C) The use of an Automated External Defibrillator.
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.

Per staff interviews, Resident#1 (R1) tested positive for a communicable disease on 7/22/24. On 7/23/24, (R2), (R3) and (R4) tested positive for a communicable disease. During records review, LPA Ramirez could not locate a report in R1, R2, R3 and R4’s file regarding an incident that threatens their health on 7/22/24 and 7/23/24. This licensing agency did not receive notification of a epidemic outbreak within 24 hours from 7/23/24. LPA Ramirez will issue a Type B deficiency based on records reviewed and interviews with staff.

One (1) deficiency was cited during visit. A copy of this report 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: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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 07/30/2024 04:04 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: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2024
Section Cited
CCR
87211(a)(1)(2)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven* Licensee will send report and retrain by 8/13/24.
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(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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 case.(A)Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.(C) The use of an Automated External Defibrillator. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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 days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the-

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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: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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