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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003840
Report Date: 06/22/2023
Date Signed: 06/22/2023 02:21:14 PM


Document Has Been Signed on 06/22/2023 02:21 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:
06/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Joselene Poy Lorenzo, CaregiverTIME COMPLETED:
02:25 PM
NARRATIVE
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purposes of conducting a case management deficiency in connection to the investigation completed under complaint control number:#22-AS-20220419091443. LPA Quiroz was greeted and granted entry into the facility and met with Licensee/Administrator David Nehem and explained the reason for the visit.
During course of the investigation of Complaint control #22-AS-20220419091443, the Department observed deficiencies in the following Title 22 California Code Of Regulations:
  • 87465(g) Incidental Medical and Dental Care
  • 87463(c) Reappraisals

Facility is being cited during today's visit.


An exit interview was conducted with Caregiver Joselene Poy Lorenzo, and a copy of this report, LIC 809-D, Appeal Rights and LIC 811-Confidential Names were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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 06/22/2023 02:21 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: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2023
Section Cited
CCR
87465(g)

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87465(g) Incidental Medical and Dental Care- The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…This requirement was not met as evidence by: Per physician report CONT BELOW...
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L/AD Nehem agreed to read and understand CCR 87465: Incidental Medical and Dental Care and submit proof of understanding to CCL by 6/23/2023.
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dated 2/4/22 R1 had a diagnosis of Dementia was sometimes confused. Following R1’s elopement and unwitnessed fall staff did not seek medical attention and have R1 assessed for injury. This poses an immediate risk to residents in care.
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Type A
06/23/2023
Section Cited
CCR87463(c)

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87463(c)Reappraisals- The licensee shall arrange a meeting with… the resident’s representative, if any, appropriate facility staff, … when there is significant change in the resident’s condition…. This requirement was not met as evidence by: Based on record review CONT BELOW
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L/AD Nehem agreed to read and understand CCR 87463:Reappraisals and submit proof of understanding to CCL by 6/23/2023.
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the licensee did not document resident’s reappraisal following R1’s change in condition following hospitalization on 3/22/22. This poses an immediate 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: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2