198603733-6-4-2025-28-AS-SVAD-DHBKTQ-20250604081129

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603733
Report Date: 06/03/2025
Date Signed: 06/04/2025 08:12:53 AM

Document Has Been Signed on 06/04/2025 08:12 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GRACE PINEDA'S HOME INC		FACILITY NUMBER:	198603733
ADMINISTRATOR/ DIRECTOR:	ULLOA, SILVIA		FACILITY TYPE:	735
ADDRESS:	347 EAST GREENHAVEN ST		TELEPHONE:	(626) 967-2961
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY: 4		CENSUS: 3	DATE:	06/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:17 PM
MET WITH:	Silvia Ulloa- Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Vaid conducted an unannounced visit to the facility for the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement Tool to evaluate the facility. LPA Vaid was allowed entry by Silvia Ulloa Licensee/Administrator and explained the purpose of the visit. The facility is licensed to serve 4 ambulatory clients aged 18 to 59. Currently, there are three (3) clients in placement, clients are provided Case Management services by San Gabriel Pomona Regional Center. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator is adhering to infection control requirements. Operational Requirements: Fire Drills are conducted every three months. Emergency Disaster/ Earthquake Drills are conducted every three months. Last drills were conducted on 03/26/25. Physical Plant & Environment Safety: The property is a single-family residence located in a residential neighborhood and consist of three (3) client bedrooms, one (1) client bathroom, one (1) staff bedroom, two (2) staff bathrooms, living room, kitchen, dining room, office, and laundry area in the attached garage. Playroom located in the rear of the facility. LPA observed appropriate furniture, lighting fixtures, personal storage space as required, Beds have adequate amount of linen and mattresses are in good repair. Continued on 809C........

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRACE PINEDA'S HOME INC	FACILITY NUMBER: 198603733
	VISIT DATE: 06/03/2025

NARRATIVE

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Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. Bathroom sinks and showers were free of mold/mildew. LPA observed that sufficient toiletries accessible to clients. Water temperature measured between and is within range of 105.0 – 120 Degrees F. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. First aid kit is fully stocked with manual, smoke alarms located in each clients bedrooms and carbon monoxide detectors were located in the hallway and are operational. No bodies of water present. Medications are stored, locked and inaccessible to clients. Hazardous toxins and/or items are inaccessible to clients. Fire extinguisher(s) are fully charged 04/08/2025. Exit, walkways and/or passageways, front and back yard are free of obstructions and hazards. Notifications and postings were observed which included personal rights, staff and client rosters, menu and emergency disaster plan.

Staffing: Sufficient staffing at the facility. Staff employed are over the age of 18, are fingerprint, cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1-S3. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator Certificate expired 06/15/2025, renewal is pending.

Client Rights-Information: Client personal rights and House Rules are posted in the dining area.

Client Records-Incident Reports: LPA reviewed Client files for C1 through C3. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources. Special Incident Reports, Client Personal Property and Clients Personal Rights.

Continued on 809C........

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRACE PINEDA'S HOME INC	FACILITY NUMBER: 198603733
	VISIT DATE: 06/03/2025

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Food Service: The facility has sufficient food supplies of 2-day perishable and 7-day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well maintained. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and pests. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1-C3. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services or restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan.

Emergency Intervention: Not Applicable.

No deficiencies were noted on today’s visit. Exit interview and copy of report were provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

LIC809 (FAS) - (06/04)

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