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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003840
Report Date: 04/27/2023
Date Signed: 04/27/2023 04:14:38 PM


Document Has Been Signed on 04/27/2023 04:14 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 & INLAND A/SC, 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:
04/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:Joselene Poy Lorenzo-CaregiverTIME COMPLETED:
04:29 PM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced Case Management visit in conjunction with complaint visit 22-AS-20230403125946. LPA Ramirez was greeted and granted entry into the facility and met with Caregiver Joselene Poy Lorenzo and explained the reason for the visit.

During the course of the complaint investigation, LPA reviewed included the Physician Report (LIC602A)
for Resident 1 (R1). Per Physician report dated 02/06/23 for R1 the primary and/or secondary diagnosis section was left blank.

A Technical Violation was issue on this date.

This report was discussed with caregiver Lorenzo and a copy was provided at the time of exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
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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