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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000970
Report Date: 05/16/2023
Date Signed: 05/16/2023 08:55:12 PM

Document Has Been Signed on 05/16/2023 08:55 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:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rossini LipioTIME COMPLETED:
03:00 PM
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On 04/11/2023, Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to conduct a Required – 1 Year Annual inspection. LPA Martinez knocked on the door several times and rang the door bell. After several knocks, Licensee's daughter Rossini Lipio answered the door. Ms. Lipio stated all Clients were at Program and staff was out. Ms. Lipio stated Licensee and Administrator were at a funeral and that she needed to leave for school. Ms. Lipio called Administrator who stated they could leave funeral and meet with LPA but don't know how long it would take. LPA stated she would return at a later date to complete Required - 1 Year Annual visit.
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On today's date, LPA Martinez made an unannounced visit to the facility to conduct the Required - 1 Year evaluation. LPA was greeted and granted entry by Staff Ruby Lipio. Licensee/Administrator Henry Balanza arrived shortly after. LPA Martinez confirmed that Administrator Balanza has a current certificate, which expires on 12/18/2024.
This facility currently has 5 clients. LPA toured the interior and exterior of the facility and inspected the physical plant, including but not limited to testing hot water temperature in client bathrooms, testing all smoke detectors and carbon monoxide detectors. Fire extinguisher was mounted and charged. The hot water temperature was measured and recorded at 107.8 degrees F. Smoke detectors and carbon monoxide detector were tested and found to be in place and operational. LPA inspected the food supply, observed medication storage, reviewed the centrally stored medications, reviewed client records and staff records. LPA reviewed facility telephone; provision of sufficient lighting; exit obstructions, if any; and potential hazards. Emergency drills are conducted monthly with the last emergency drill being conducted 04/27/2023 and documentation was available for review. Hygiene supplies are provided for number of client's in care. Food supply was noted to be in sufficient quantities to meet the regulatory requirements of a 2-day perishables and 7-day non-perishables.
Based on this inspection, no deficiencies were observed at this time in the areas evaluated.
This report was discussed with AD Balanza and a copy of this report will be sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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