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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005470
Report Date: 11/25/2024
Date Signed: 12/04/2024 01:31:01 PM

Document Has Been Signed on 12/04/2024 01:31 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GRACES HOMEFACILITY NUMBER:
306005470
ADMINISTRATOR/
DIRECTOR:		MAI, NGOCFACILITY TYPE:
740
ADDRESS:2152 S JETTY DRTELEPHONE:
(714) 553-1166
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:MIa Ng0cTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samer Haddadin made an unannounced required annual inspection at this facility. LPA met with Administrator Mai Ngoc and stated the purpose of this visit.

The facility is a single level home and licensed for six non-ambulatory of which two may be bedridden with a hospice waiver for six. This facility is a Residential Care Facility for the Elderly/Dementia. The facility had 6 bedrooms in which 4 are used for resident and 2 for staff members.

LPA toured the interior and exterior portions of the facility. Resident rooms were provided with furniture, chair, clean linen, adequate storage space, and kept free of tripping hazards. Hard wired smoke detectors, carbon monoxide and audible exit alarms were tested to be operational. LPA did not observe the required PUB 475 to be in the right size. Also, LPA asked AD for liability insurance, AD stated he does not have one currently on his person will provide it. LPA did not observe any emergency drill documentation. All files of staff and clients contained all required documentation.

Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 126.6 degrees Fahrenheit. Facility did not met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements.

For the exterior portion, facility did not have a shaded area and nor chairs; grounds were unclear of tripping hazards and no space for activities. Facility has a 2-car garage and is kept locked and used for storage; the garage also had an operational washer and dryer.

Based on this inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. .

***THIS IS AN AMENDED REPORT***

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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 4
Document is an Amendment of Original Document on 12/04/2024 10:49 AM


Created By: Samer Haddadin On 11/25/2024 at 02:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACES HOME
FACILITY NUMBER: 306005470

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by hot water measuing 126.6 degree F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2024
Plan of Correction
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4
This is an emmended report. Original POC date as the 26th of Nov. AD, Mai Ngoc , was advised of POC date on the 26th of Nov
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document is an Amendment of Original Document on 12/04/2024 11:02 AM


Created By: Samer Haddadin On 11/25/2024 at 02:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACES HOME
FACILITY NUMBER: 306005470

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and recored review, the licensee did not comply with the section cited above by not having valid libility insurance which poses an potential health, safety or personal rights risk to persons in care.

***THIS IS AN EMDED REPORT***
POC Due Date: 01/01/2025
Plan of Correction
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4
This is an emended deficiency .AD, Mai Ngoc , was advised of POC date on the 26th of Nov
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having uncleared backyard nor space for residents activity which poses an potential health, safety or personal rights risk to persons in care.
***THIS IS AN AMENDED REPORT***
POC Due Date: 01/01/2025
Plan of Correction
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2
3
4
This is an emended deficiency .. AD, Mai Ngoc , was advised of POC date on the 26th of Nov
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 Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document is an Amendment of Original Document on 12/04/2024 11:12 AM


Created By: Samer Haddadin On 11/25/2024 at 02:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACES HOME
FACILITY NUMBER: 306005470

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(h)(2)
Planned Activities
(h) Facilities shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas which are easily accessible to residents and protected from traffic. Gardens or yards shall be sufficient in size, comfortable, and appropriately equipped for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by which poses an potential health, safety or personal rights risk to persons in care.

***THIS IS AN AMENDED REPORT***
POC Due Date: 01/01/2025
Plan of Correction
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2
3
4
This is an emended deficiency . Original POC date as the 26th of Nov. AD, Mai Ngoc , was advised of POC date on the 26th of Nov
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4