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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003772
Report Date: 08/15/2024
Date Signed: 08/15/2024 12:18:22 PM


Document Has Been Signed on 08/15/2024 12:18 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
ORANGE COUNTY ASC, 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: 0DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Lorenzo De Garriz - Administrative AssistantTIME COMPLETED:
12:33 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by Lorenzo Degarriz, Assistant. Administrator. Administrator Evelyn Degarriz joined the inspection via phone call.

The facility currently has no residents in care due to renovations occurring. AD stated residents were moved to a nearby facility. LPA contacted the nearby facility's Administrator (AD2) who confirmed the two residents relocated there on 3/1/2024. AD2 also stated that the two residents lived at a different facility after leaving Divine Grace.LPA contacted the Administrator of the 3rd facility (AD3). AD3 confirmed the two residents lived at AF. Based on interviews with AD, AD2 and AD3, LPA determined the two residents moved out of Divine Grace Villa on 6/1/2023 and 6/28/2023. Divine Grace Villa AD stated the facility completed flooring renovations in August 2022 and the kitchen remodel was completed in October 2023. LPA requested invoices for the flooring and kitchen remodel, but the AD stated they would need to send them to the LPA when they get to their computer. A technical advisory was issued. LPA observed a permit indicating the roof construction was completed on 6/11/2024. LPA observed a notice stating the painting of the facility will begin in 1-3 days of receipt of the notice. LPA obtained photos of the permit and notice.
The facility is a one-story home with 4 resident bedrooms, 2 resident bathrooms, kitchen/dining room, living room, backyard, laundry room, storage sheds and detached 2-car garage. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and supplies for residents in the garage. Restrooms are stocked with soap and paper towels. LPA measured water in resident bathrooms to be between 105 and 120 degrees Fahrenheit.

Based on today's inspection, no deficiencies and one technical advisory are being issued. An exit interview was conducted and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
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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