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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003840
Report Date: 05/19/2023
Date Signed: 05/19/2023 04:08:08 PM


Document Has Been Signed on 05/19/2023 04:08 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
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:
05/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Joselene Poy Lorenzo-CaregiverTIME COMPLETED:
04:25 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced visit to conduct a Plan of Corrections (POC) based upon a Technical Violation (LIC9102TV) issued on 04/27/23. LPA Ramirez was allowed entry into the facility and initially met with Caregiver Joselene Poy Lorenzo and explained the purpose of the visit.

On today's visit LPA reviewed the file for R1 and did not observe an updated Physician Report (LIC602) for R1. Licensee did not email LPA an updated Physician Report (LIC602) and the Services and Needs indicating how R1 is a compatible resident to their facility. Updated information for R1 was due on 05/11/23.

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

This report was discussed with the facility representative and a copy was provided as well as Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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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Document Has Been Signed on 05/19/2023 04:08 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: GRACIOUS CARE HOMES
FACILITY NUMBER: 306003840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2023
Section Cited
CCR
87458(b)(1)

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87458 Medical Assessment: (b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis...or other medical conditions which would preclude care of the person by the facility.
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 Licensee to obtained an updated physician report for R1 and update the Services and Needs indicating how R1 is a compatible resident to their facility and email proof to LPA by 05/26/23.
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This requirement is not met as evidence by: Physician report dated 02/06/23 for resident 1 (R1) does not have a primary and/or secondary diagnosis. This poses a potential helath and safety risk to residents in care.
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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) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
LIC809 (FAS) - (06/04)
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