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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003772
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:54:35 PM


Document Has Been Signed on 08/25/2022 12:54 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: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:
08/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Evelyn De GarrizTIME COMPLETED:
10:35 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Administrator Evelyn De Garriz and explained the reason for the visit.

At 8:51 AM, LPAs toured the facility with Administrator De Garriz. Facility has 2 clients present during today's visit with one on hospice. LPAs observed clients relaxing in the facility. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer. At 8:55 AM, LPAs observed unsecured vitamins in Licensee room. LPAs observed the screening/ sanitizing station in the entrance of the facility. The facility mitigation plan has been completed as well as infection control. LPAs observed the first aid kit contained all required items. At 9:00 AM, LPAs observed medication cupboard is unlocked and accessible to residents in care as well as unsecured scissors, knife in the kitchen and cleaning materials in the washer/ dryer alcove. LPAs observed facility has ample 2 day perishables and 7 day non-perishables in facility kitchen. Facility has emergency food and water. Fire extinguishers are mounted and charged. At 9:20 AM, LPAs toured the outside grounds and observed trash and boxes throughout the yard. LPAs observed the patio area off the garage is cluttered, unkempt and filled with flies. The yard has dog urine and feces throughout the outside area. LPAs observed unsecured scissors and paint in the yard as well. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPsA reviewed all resident files and observed emergency information in the file.


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: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
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


Document Has Been Signed on 08/25/2022 12:54 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
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: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
The following shall be stored inaccessible to residents with dementia
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.


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. LPAs observed unsecured vitamins, scissors, knife, paint and cleaning supplies as noted in LIC 809. Resident 1 is diagnosed with Dementia. This poses an immediate health and safety risk to persons in care.
POC Due Date: 08/26/2022
Plan of Correction
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Licensee to secure noted items and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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. LPAs observed the medication cupboard is unlocked and medications are accessible to residents in care This poses an immediate health and safety risk to persons in care.
POC Due Date: 08/26/2022
Plan of Correction
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Licensee to secure cupboard and forward proof to LPA by POC due date. Licensee secured cupboard during visit.

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: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/25/2022 12:54 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
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: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.


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. LPAs observed dog feces and urine as well as flies, and clutter in the patio. (photos). This poses an immediate health and safety risk to persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Licensee to clean area 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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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: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3