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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003840
Report Date: 11/16/2023
Date Signed: 11/16/2023 04:21:17 PM


Document Has Been Signed on 11/16/2023 04:21 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: 6DATE:
11/16/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:06 PM
MET WITH:Joselene Poy LorenzoTIME COMPLETED:
04:35 PM
NARRATIVE
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This unannounced POC inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of verifying correction of deficiencies issued during the Required – 1 Year Inspection conducted on 09/22/23 and the POC inspection conducted on 10/23/23. LPA met with Staff #1 (S1) Joselene Poy Lorenzo and discussed the purpose of the inspection. Administrator (AD) David Nehem was not present during the inspection. House Manager (HM) Virgilio Galang appeared via telephone. During the inspection, LPA and S1 toured the facility, reviewed documents, and observed the following:

Type B Violation cited under Health & Safety Code (HSC) section 1569.625(b)(2) pertaining to 20-hour annual staff training has not been cleared. Per HM, S6 no longer works at the facility. LPA reviewed training records for S5 and observed only 2 hours of training pertaining to postural supports, restricted health conditions, and hospice care. Civil penalties are being assessed.

Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87405(a) pertaining to administrator qualifications has not been cleared. Per HM, the previous administrator resigned and has not been replaced and the facility does not have an administrator. Civil penalties are being assessed.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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 11/16/2023 04:21 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: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/14/2023
Section Cited
HSC
1569.625(b)(2)

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§1569.625 … (2) … training requirements shall also include an additional 20 hours annually, eight hours of … dementia care training … four hours of … postural supports, restricted health conditions, and hospice care This requirement was not met as evidenced by:
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Licensee stated they will have the staff complete the training and submit proof to LPA by POC due date.
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Based on documents, the licensee did not ensure S5 completed 4 hours on postural supports, restricted conditions, and hospice, which poses a potential health risk to persons in care. CIVIL PENALTY ASSESSED.
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Type B
12/14/2023
Section Cited
CCR87405(a)

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87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. This requirement was not met as evidenced by
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Licensee stated they will appoint an administrator and submit proof to LPA by POC due date.
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Based on documents and interview, the facility currently does not have an administrator, which poses a potential health risk to persons in care. CIVIL PENALTY ASSESSED.
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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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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