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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003840
Report Date: 02/17/2022
Date Signed: 02/17/2022 12:08:40 PM


Document Has Been Signed on 02/17/2022 12:08 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:GRACIOUS CARE HOMESFACILITY NUMBER:
306003840
ADMINISTRATOR:DAVID NEHEM/S.MITCHELLFACILITY TYPE:
740
ADDRESS:4110 E. JORDAN AVENUETELEPHONE:
(714) 289-1946
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:David Nehem, AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of conducting a required annual inspection visit. LPA arrived at facility, explained the purpose of the visit and was greeted by the caregiving staff and granted entry after being screened. Administrator David Nehem arrived shortly after being called by caregiving staff.

At approximately 9:50am, LPA accompanied by caregivers began the tour of the facility. There are currently 4 residents in care, including 1 on hospice. The residents are observed relaxing in the common area or in their bedrooms and appear well taken care of. Facility appears to be clean, sanitary and free of odors in all areas inspected. LPA observed a check-in station right at the entrance of the facility where visitors temperature checks are being documented. LPA observed the facility has COVID-19 Precautions posters, all required department postings, and hand washing signs posted throughout. LPA observed a sufficient supply of food and water. Facility has an adequate supply of PPE stored in the attached garage. LPA toured the outside of the facility and observed outdoor seating for the residents' enjoyment. Outdoor space is free of debris and well-maintained with self-latching gates that can easily be opened. All six (6) individual bedrooms were observed to have all required components. Bathrooms are equipped with grab bars and slip mats.

The facility has completed and submitted their LIC808 Mitigation Plan.

Based on the observations made during today’s visit, deficiencies are being cited today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representative and a copy of this and appeal rights was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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 2


Document Has Been Signed on 02/17/2022 12:08 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: GRACIOUS CARE HOMES
FACILITY NUMBER: 306003840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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The refrigerator is indicated to be kept shut by a latching device at night. This is not in compliance with CCR Section 87468.1 (a) (3) (Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from (...) interfering with daily living functions such as eating, sleeping, or elimination.as evidenced by the restricted access to food).
POC Due Date: 02/17/2022
Plan of Correction
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The latching device was removed immediately by staff.
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) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2