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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003772
Report Date: 08/16/2021
Date Signed: 08/16/2021 03:09:39 PM

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:DIVINE GRACE VILLAFACILITY NUMBER:
306003772
ADMINISTRATOR:EVELYN DE GARRIZFACILITY TYPE:
740
ADDRESS:9662 KATELLA AVENUETELEPHONE:
(714) 533-0841
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 2DATE:
08/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Carolina Concepcion and Lorenzo De GarrizTIME COMPLETED:
02:35 PM
NARRATIVE
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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 Carolina Concepcion and explained the reason for the visit. Licensee's son Lorenzo De Garriz was present and assisted with the visit.

At 12:45 PM, LPA toured the facility with Lorenzo De Garriz. Facility has 2 clients present during today's visit. LPA observed clients relaxing in the facility. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPA did not observe a screening/ sanitizing station in the entrance of the facility nor documentation of temperatures taken for staff or residents. Facility has covid precaution postings but did not observe required department postings. The facility mitigation plan has been completed and is pending approval. LPA observed the first aid kit. At 1:00 PM, LPA observed medication cupboard is unlocked and accessible to residents in care as well as a resident's pre-poured medication box sitting on the dining room table unsecured. Fire extinguishers are mounted and charged. LPA toured the outside grounds and observed the outside shaded visitation area. LPA observed the patio area off the garage is cluttered and unkempt. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. All staff and clients are vaccinated for Covid-19. LPA reviewed all resident files and observed emergency information in the file. Resident 1(R1) has a physician report dated 10/11/2016 with a diagnosis of Mild Cognitive Impairment and R(2) has a physician report dated 06/26/2019 with a diagnosis of Dementia.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DIVINE GRACE VILLA
FACILITY NUMBER: 306003772
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)


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. LPA observed medication cupboard is unlocked as well as a pre-poured medication box is sitting on the dining room table unsecured which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/17/2021
Plan of Correction
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Licensee to secure noted items and forward proof to LPA by POC due date.
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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DIVINE GRACE VILLA
FACILITY NUMBER: 306003772
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

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 one out of two resident files. R2 has a physician report dated 06/26/2019 and has a diagnosis of Dementia which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 08/30/2021
Plan of Correction
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Licensee to obtain a current physician report and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3