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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003833
Report Date: 04/13/2024
Date Signed: 04/13/2024 06:26:26 PM


Document Has Been Signed on 04/13/2024 06:26 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:GRACE'S HOME #2FACILITY NUMBER:
306003833
ADMINISTRATOR:VLADIMIR VELEZFACILITY TYPE:
740
ADDRESS:12501 BROWNING AVENUETELEPHONE:
(714) 508-3523
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 4DATE:
04/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:21 PM
MET WITH:Facility Administrator - Vladimir VelezTIME COMPLETED:
06:45 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual. LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) Vladimir Velez. The PUB475 "See Something, Say Something" poster was observed to be posted in the living room. LPA observed the Administrator's Certificate for Vladimir Velez, which expired on 1/9/2024, however provided proof of certification renewal submitted on 1/6/2024, and an AD certificate for Sonia Velez which expires on 9/22/2024.

LPA De Perio toured the interior and exterior portions of the facility with AD Velez. The facility is a single level structure and is licensed for 6 residents, of which 1 may be bedridden and 6 may be on hospice. There are a total of 5 bedrooms, of which 2 are private, and 2 are shared and 1 designated for staff. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 4 restrooms, which were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 114.2 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care and is located in a drawer. Fire extinguisher was charged, mounted and located by the hallway.



LPA De Perio observed the emergency disaster and evacuation plan, which is located in a folder. Facility had back-up emergency food and water supply, located in the kitchen and in the garage. LPA De Perio observed that First Aid Kit had all the required components. Medications and toxins were observed to be locked and inaccessible to residents.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE'S HOME #2
FACILITY NUMBER: 306003833
VISIT DATE: 04/13/2024
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For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which were self-closing and self-latching. LPA observed a body of water in the backyard, however is made inaccessible to residents in care by a locked gate.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

No citations were issued.

An exit interview was conducted with AD Velez.

A copy of this report was explained and provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2024
LIC809 (FAS) - (06/04)
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