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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003840
Report Date: 10/23/2023
Date Signed: 10/23/2023 03:30:26 PM


Document Has Been Signed on 10/23/2023 03:30 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:
10/23/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Joselene Poy LorenzoTIME COMPLETED:
03:45 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. LPA met with Staff #1 (S1) Joselene Poy Lorenzo and discussed the purpose of the inspection. Administrator (AD) Leonora Cheryll Amorsolo 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 1569.618(c)(3) pertaining to CPR training has been CLEARED. On 10/12/23, AD submitted to LPA CPR training certificates for S1, Staff #2 (S2), and Staff #3 (S3).

Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87412(a)(11) pertaining to staff health screenings has not been cleared. LPA reviewed health screenings for S1, S2, S3, Staff #4 (S4), and Staff #5 (S5). However, the health screenings for S1, S2, and possibly S3 were not signed by doctors. LPA issued a technical violation.

Type B Violation cited under HSC section 1569.625(b)(1) pertaining to 40-hour initial staff training has been CLEARED. On 10/12/23, AD submitted to LPA 40-hour initial training records for S1 and S2. During today’s inspection, LPA reviewed S1 and S2’s files and obtained documentation of additional training.

Type B Violation cited under HSC section 1569.625(b)(2) pertaining to 20-hour annual staff training has not been cleared. During today’s inspection, LPA reviewed staff files for S5 and Staff #6 (S6) and observed that while they completed 20-hours of training, S5 and S6 did not complete 4 hours of training specific to postural supports, restricted health conditions, and hospice care and S6 did not complete 8 hours specific to Dementia. Civil penalties are being assessed.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
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 3


Document Has Been Signed on 10/23/2023 03:30 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: 10/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/13/2023
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 ensure S5 and S6 complete the required training and submit proof to LPA by POC due date.

CIVIL PENALTY ASSESSED.
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Based on documents, the licensee did not ensure S5 and S6 completed 8 hours on dementia and 4 hours on postural supports, restricted conditions, and hospice, which poses a potential health risk to persons in care.
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Type B
11/13/2023
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 submit all required documents to appoint an administrator by POC due date.
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Based on documents, the corporate licensee did not designate an administrator via board resolution, which poses a potential health risk to persons 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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 10/23/2023
NARRATIVE
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Type B Violation cited under CCR section 87411(c)(1) pertaining to first aid training has been CLEARED. On 10/12/23, AD submitted to LPA first aid training certificates for S1 and S2.

Type B Violation cited under HSC section 1569.69(a)(2) pertaining to initial staff medication training has been CLEARED. During today’s inspection, LPA reviewed S1’s file and obtained documentation of an additional 8 hours of medication training completed on 10/02/23.

Type B Violation cited under HSC section 1569.695(c) pertaining to emergency disaster drills has been CLEARED. On 10/12/23, AD submitted to LPA a procedure for conducting emergency disaster drills and proof of a drill conducted on 09/29/23.

Type B Violation cited under CCR section 87608(a)(5)(A) pertaining to bed rails has been CLEARED. During today’s inspection, LPA observed full bed rails on the beds of Resident #1 (R1) and Resident #2 (R2) and half bedrails on the bed of Resident #3 (R3). LPA reviewed resident files and confirmed doctors’ orders for these bedrails and that R1 and R2 are on hospice.

On 10/12/23, AD sent LPA an LIC308 Designation of Facility Responsibility designating her as the Administrator. As the licensee is a corporation, on 10/16/23, LPA requested a copy of the board minutes appointing AD as the administrator. As of today’s visit, the board minutes have not been received.

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, clear letters for all citations cleared during this inspection, 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: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC809 (FAS) - (06/04)
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