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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005470
Report Date: 11/29/2021
Date Signed: 11/29/2021 02:47:24 PM

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:GRACES HOMEFACILITY NUMBER:
306005470
ADMINISTRATOR:MAI, NGOCFACILITY TYPE:
740
ADDRESS:2152 S JETTY DRTELEPHONE:
(714) 553-1166
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:6CENSUS: 2DATE:
11/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Ngoc MaiTIME COMPLETED:
01:00 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and was granted entry into the facility by Administrator Ngoc Mai. LPA Tirre explained the reason for the visit.

During the visit LPA toured the facility with Administrator, Facility is a 6 bedroom (4 resident rooms 2 staff rooms) and 2 bathroom single story home. There are 2 Clients in care. LPA observed proper covid signage at front entrance of facility. Facility has required Department postings. LPA toured resident rooms, all rooms had beds, closet space, dresser and working lights . Facility has 2 restrooms, 1 which is currently not in use and is under construction. The other restroom had working water basin, toilet, toilet paper, soap and hand towels. Residents were observed relaxing in living room watching TV.

Facility has supplies of PPE but not 30 days supply, LPA reminded Administrator of Department guidelines. Facility has food supply of perishable and non perishable foods. Facility has a secured location for Resident medication and files. Facility does not have a 30 days supply of medications for Residents. LPA reviewed Residents files during visit. Residents Emergency contact Information is current.

An exit interview was conducted with Administrator and copy of report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
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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