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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306003840
Report Date:
09/22/2023
Date Signed:
09/22/2023 03:59:07 PM
Document Has Been Signed on
09/22/2023 03:59 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 HOMES
FACILITY NUMBER:
306003840
ADMINISTRATOR:
DAVID NEHEM/S.MITCHELL
FACILITY TYPE:
740
ADDRESS:
4110 E. JORDAN AVENUE
TELEPHONE:
(714) 289-1946
CITY:
ORANGE
STATE:
CA
ZIP CODE:
92869
CAPACITY:
6
CENSUS:
6
DATE:
09/22/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
08:30 AM
MET WITH:
Joselene Poy Lorenzo, David Nehem
TIME COMPLETED:
04:10 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Joselene Poy Lorenzo and discussed the purpose of the inspection. Administrator (AD) Leonora Cheryll Amorsolo arrived during the inspection.
LPA reviewed Infection Control requirements. At about 9:00AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: this is a one-story home. Facility is a 7-bedroom, 3-bathroom, one-story house with attached garage that is being used for storage. LPA observed 4 staff and 6 residents present at the facility. Resident Bedrooms: the 6 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: the 1 staff bedroom is spacious and will easily accommodate the staff’s furnishings. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 105.9 degrees F in the bathroom near the kitchen, 111 in the hallway bathroom, and 107 in the bedroom bathroom after corrections. LPA inspected all rooms in the facility. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and garage after corrections. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. LPA discussed licensing fees with AD. At about 11:00AM, LPA reviewed 6 resident files and 6 staff files, interviewed 6 residents and 1 staff, and inspected medications for 6 residents. Facility does not handle resident money.
SUPERVISOR'S NAME:
Armando J Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Sean Haddad
TELEPHONE:
(714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE:
09/22/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/22/2023
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
16
Document Has Been Signed on
09/22/2023 03:59 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:
09/22/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not ensure lighter fluid, engine degreaser, toxins, and large metal saws were inaccessible to residents including those with dementia in the non-lockable garage, which poses an immediate safety risk to persons in care.
POC Due Date:
09/23/2023
Plan of Correction
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2
3
4
During the inspection, the licensee secured these items and LPA confirmed. POC CLEARED.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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 Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Sean Haddad
TELEPHONE:
(714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE:
09/22/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/22/2023
LIC809
(FAS) - (06/04)
Page:
2
of
16
Document Has Been Signed on
09/22/2023 03:59 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:
09/22/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure proper water temperatures when the faucet in the hallway bathroom used by residents tested at 128.4 degrees F, which poses a potential safety risk to persons in care.
POC Due Date:
09/29/2023
Plan of Correction
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During the inspection, the licensee adjusted the water temperature to be within proper range and LPA confirmed. POC CLEARED.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff statements and documents, none of the staff present (S1, S2, S3) have proof of CPR training, which poses a potential safety risk to persons in care.
POC Due Date:
10/20/2023
Plan of Correction
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Licensee stated they will enroll staff in CPR training and submit proof of completion by POC due date.
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 Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Sean Haddad
TELEPHONE:
(714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE:
09/22/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/22/2023
LIC809
(FAS) - (06/04)
Page:
3
of
16
Document Has Been Signed on
09/22/2023 03:59 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:
09/22/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on documents, the licensee did not obtain health screenings for S1, S2, S3, S4, and S5, which poses a potential safety risk to persons in care.
POC Due Date:
10/20/2023
Plan of Correction
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Licensee stated they will obtain health screenings for staff and will submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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4
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 Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Sean Haddad
TELEPHONE:
(714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE:
09/22/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/22/2023
LIC809
(FAS) - (06/04)
Page:
4
of
16
Document Has Been Signed on
09/22/2023 03:59 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:
09/22/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on administrator's statement and documents, the licensee did not ensure S1 and S2 completed the 40-hour initial training timely, which poses a potential health risk to persons in care.
POC Due Date:
10/20/2023
Plan of Correction
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2
3
4
Licensee stated they will ensure these staff complete the training and will submit proof to LPA by POC date.
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 Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Sean Haddad
TELEPHONE:
(714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE:
09/22/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/22/2023
LIC809
(FAS) - (06/04)
Page:
5
of
16
Document Has Been Signed on
09/22/2023 03:59 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:
09/22/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on documents, the licensee did not ensure S5 and S6 completed the 20-hour annual training, which poses a potential health risk to persons in care.
POC Due Date:
10/20/2023
Plan of Correction
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3
4
Licensee stated they will ensure these staff complete the training and will submit proof to LPA by POC due date.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on administrator's statements and documents, the licensee did not ensure S1 and S2 had first aid training, which poses a potential safety risk to persons in care.
POC Due Date:
10/20/2023
Plan of Correction
1
2
3
4
Licensee stated they will ensure all staff receive first aid training and will submit proof to LPA by POC due date.
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 Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Sean Haddad
TELEPHONE:
(714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE:
09/22/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/22/2023
LIC809
(FAS) - (06/04)
Page:
6
of
16
Document Has Been Signed on
09/22/2023 03:59 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:
09/22/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on administrator statements and documents, the licensee did not ensure S1 who provides assistance with medications received the 4 hours of other training or instruction, which poses a potential health risk to persons in care.
POC Due Date:
10/20/2023
Plan of Correction
1
2
3
4
Licensee stated they will have S1 complete this training and will submit proof to LPA by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on documents, the licensee does not maintain records of emergency disaster drills, which poses a potential safety risk to persons in risk.
POC Due Date:
10/20/2023
Plan of Correction
1
2
3
4
Licensee stated they will conduct an emergency disaster drill and submit proof to LPA by POC due date and will conduct them at least quarterly in the future.
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 Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Sean Haddad
TELEPHONE:
(714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE:
09/22/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/22/2023
LIC809
(FAS) - (06/04)
Page:
7
of
16
Document Has Been Signed on
09/22/2023 03:59 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:
09/22/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and documents, 5 residents had half bed rails and 1 resident on hospice had a full bedrail but there were no orders for bedrails present at the facility, which poses a potential personal rights risk to persons in care.
POC Due Date:
10/20/2023
Plan of Correction
1
2
3
4
Licensee stated they will follow up with all residents doctors to obtain orders and for residents without orders will remove the rails and submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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 Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Sean Haddad
TELEPHONE:
(714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE:
09/22/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/22/2023
LIC809
(FAS) - (06/04)
Page:
8
of
16
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
VISIT DATE:
09/22/2023
NARRATIVE
1
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3
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5
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14
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27
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32
During the inspection, LPA and AD observed the following: the licensee did not ensure lighter fluid, engine degreaser, toxins, and large metal saws were inaccessible to residents including those with dementia in the non-lockable garage; the licensee did not ensure proper water temperatures when the faucet in the hallway bathroom used by residents tested at 128.4 degrees F; none of the staff present (S1, S2, S3) have proof of CPR training; the licensee did not obtain health screenings for S1, S2, S3, S4, and S5; the licensee did not ensure S1 and S2 completed the 40-hour initial training timely; the licensee did not ensure S5 and S6 completed the 20-hour annual training; the licensee did not ensure S1 who provides assistance with medications received the 4 hours of other training or instruction; the licensee does not maintain records of emergency disaster drills; 5 residents had half bed rails and 1 resident on hospice had a full bedrail but there were no orders for bedrails present at the facility; and the licensee did not ensure S1 and S2 had first aid training.
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. 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 Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Sean Haddad
TELEPHONE:
(714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE:
09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/22/2023
LIC809
(FAS) - (06/04)
Page:
16
of
16