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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003772
Report Date: 09/10/2021
Date Signed: 09/10/2021 09:26:11 AM

Document Has Been Signed on 09/10/2021 09:26 AM - 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:
09/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Evelyn De GarrizTIME COMPLETED:
09:50 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Jenifer Tirre made an unannounced case management visit to follow up on citations issued on 08/16/2021. LPAs were greeted and granted entry into the facility by Licensee/ Administrator Evelyn De Garriz and explained the reason for the visit.

At 8:45 AM, LPAs toured the facility and observed the following:

*Deficiency cited under Title 22 Regulation 87465(h)(2) has been cleared. Medications are secured in a locked cabinet. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87705(c)(5) has been cleared. Licensee obtained current physician report for Resident 2. Licensee has complied with the terms of the POC.

Advisory note issued on 08/16/2021 advised licensee to post required department postings. LPAs observed department postings are not posted in the facility.

Advisory note issued 08/16/2021 advised facility to screen all who enter facility. LPAs observed the sign-in sheet and screening area.

LPAs observed outside the patio area is still cluttered and unkempt.

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 Licensee and a copy of the report was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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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Document Has Been Signed on 09/10/2021 09:26 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 09/10/2021 at 09:11 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: DIVINE GRACE VILLA
FACILITY NUMBER: 306003772

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2021
Section Cited
CCR
87468(c)

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Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. This requirement is not being met as evidenced by:
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Licensee to post all required department postings including the "Let Us Know" poster in the correct size and forward proof to LPA by POC due date.
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LPAs observed there are no department postings in the entrance of the facility. This poses a potential health and safety risk to residents in care.
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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 Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2021


LIC809 (FAS) - (06/04)
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