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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003840
Report Date: 06/16/2022
Date Signed: 06/16/2022 04:13:24 PM


Document Has Been Signed on 06/16/2022 04:13 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: 3DATE:
06/16/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:29 PM
MET WITH:Abby MungcalTIME COMPLETED:
04:33 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced health and safety case management visit to follow up on a death report received by Community Care Licensing on 06/14/2022. LPA Lyman met with Caregiver Abby Mungcal and explained the reason for the visit. Licensee Brian Nehem arrived during the visit.

Death report dated 06/13/2022 indicated Resident 1 (R1) had been found unresponsive by staff in the resident's room. 911 was called and police responded as well as the coroner. Coroner report pending and facility to forward a copy of the death certificate once received.

At 3:40 PM, LPA Lyman toured the facility. LPA observed and spoke with residents in care. All residents appeared clean and happy with care provided. LPA observed R1's room in the front of the home. LPA toured the kitchen and it was observed to have a 2-day supply of perishable foods and a 7-day supply of non-perishable food supply. LPA observed the locked medication area. Facility appears clean and sanitary and is following covid-19 protocols. LPA reviewed and obtained pertinent documentation such as skilled nursing and hospital discharge paperwork. Licensee to forward a copy of the LIC 500 and staff schedule to LPA by close of business 06/17/2022.

No health and safety violations noted during today's visit.

An exit interview was conducted and copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
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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