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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000970
Report Date: 05/12/2022
Date Signed: 05/12/2022 03:35:20 PM

Document Has Been Signed on 05/12/2022 03:35 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GRACE RESIDENTIAL CARE 1FACILITY NUMBER:
306000970
ADMINISTRATOR:HENRY BALANZAFACILITY TYPE:
735
ADDRESS:10442 DAKOTA AVENUETELEPHONE:
(714) 539-7103
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 6CENSUS: 5DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Ruby Alipio and Henry BalanzaTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Ruby Alipio and explained the reason for the visit. Administrator Henry Balanza arrived during the visit. Henry Balanza has a current administrator certificate expiring on 12/18/2022.

At 9:30 AM, LPA toured the facility with Administrator Henry Balanza. Facility has 5 clients present during today's visit. LPA observed clients participating in zoom activities as well as playing with puzzles. Facility appears clean and sanitary. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer and paper towels. Restrooms have posted hand washing signs. LPA observed the sanitizing station in the entrance of the facility. Facility takes client and staff temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. The facility mitigation plan has been completed and approved. LPA observed adequate emergency food and water as well as the first aid kit. First aid kit contained all required items. LPA observed ample food supply as well as a posted menu. LPA observed locked medication drawer. Facility utilizes a medication administration record. Fire extinguishers are mounted and charged. LPA toured the outside grounds and observed the outside shaded visitation area. Exit gates are unlocked and self latching. Facility provides activities in the form of coloring, puzzles and outings in the community. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. LPA observed an ample supply of PPE. All staff and clients are vaccinated for Covid-19. LPA reviewed all client files and all files contained required documentation including updated emergency information.


No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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