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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005470
Report Date: 11/24/2025
Date Signed: 11/24/2025 12:42:53 PM

Document Has Been Signed on 11/24/2025 12:42 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: 5DATE:
11/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Administrator Ngoc Mai TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On November 24, 2025, Licensing Program Analyst (LPA) Garlli Tat conducted an unannounced visit to the facility for the purpose of a required annual inspection. LPA explained the purpose for the visit and was greeted and granted entry by Administrator (AD), Ngoc Mai. For this visit, there are two staff members on duty, including the AD, both of which are background cleared and associated.

The PUB475 ‘See Something, Say Something’ poster was observed to be located in the hallway. LPA observed the Administrator's Certificate for Ngoc Mai, which expires on July 11, 2027.

The facility is a Residential Care facility for the Elderly (RCFE) licensed for six residents, six of which may be non-ambulatory, two of which may be bedridden, and a hospice waiver for six. LPA toured the interior and exterior portions of the facility with the AD. For this visit, there are a total of two non-ambulatory and three ambulatory residents in care, one is on hospice, and none are bedridden.

The facility is a single story home. There are a total of six bedrooms, five of which are resident bedrooms, and one bedroom is for staff. LPA toured each bedroom with the AD and observed that bedrooms were provided with furniture in good repair, clean linens, and adequate storage space. LPA observed the staff room is kept locked and inaccessible to residents in care. Smoke and carbon monoxide detectors as well as auditory exit alarms were tested and operational. There are a total of two bathrooms for both staff and residents.

Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 11/24/2025 12:42 PM - It Cannot Be Edited


Created By: Garlli Tat On 11/24/2025 at 11:28 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACES HOME
FACILITY NUMBER: 306005470

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 interview and record review, the licensee did not have First Aid certification for himself or staff on duty at the time of the visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2025
Plan of Correction
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Licensee will ensure that at least one staff on duty that are First Aid certified at any given time. Licensee will provide proof to CCLD by POC due date.
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
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Based on record review, Staff #2 does not have 20 hours of training at the time of the visit, which poses a potential health, safety or personal rights risk to persons in care. Staff #2 has 12 hours of training.
POC Due Date: 12/24/2025
Plan of Correction
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Licensee will ensure Staff #2 completes at least 20 hours of training and submit proof to CCLD 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Garlli Tat
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/24/2025 12:42 PM - It Cannot Be Edited


Created By: Garlli Tat On 11/24/2025 at 11:28 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACES HOME
FACILITY NUMBER: 306005470

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, Resident #3 did not have a signed admission agreement on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2025
Plan of Correction
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Licensee will obtain a signed admission agreement by resident or authorized representative and keep it in resident's file and send proof to CCLD 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
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Based on record review, the licensee did not conduct quarterly emergency drills with staff and residents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2025
Plan of Correction
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Licensee will conduct and document quarterly emergency drills (i.e., fire, flood, earthquake, active shooter, etc.) and keep in log. Licensee will send copy to CCLD 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Garlli Tat
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
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
VISIT DATE: 11/24/2025
NARRATIVE
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Bathrooms were observed to be in good repair, toilets and faucets were operational and showers were equipped with grab bars and non-skid floor mats. Water temperature in the bathrooms were measured to be 112.6 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked in the kitchen cabinet and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen. Fire extinguisher had a purchase date of June 1, 2025. LPA observed the emergency disaster and evacuation plan, which is in a binder in the office. Facility had back-up emergency food and water supply, located in the garage. LPA observed that the First Aid kit had all the required components. Medications were observed to be locked in a cabinet in the kitchen, inaccessible to residents in care. Chemicals were observed to be locked underneath the kitchen sink and in the garage. LPA observed the door leading to the attached two car garage is kept locked and inaccessible to residents in care. The garage is used for storage and laundry.



For the exterior portion, LPA observed patio furniture under shading and there are two exit gate in the backyard that can be opened in case of an emergency. There is a shed in the backyard which is locked and used for storage. No bodies of water were observed.

During this visit, five resident files and two staff files were reviewed. All staff are background cleared and associated with the facility. LPA reviewed residents’ medication and medication records.

Based on today's observations, there are deficiencies being cited per Title 22 of the California Code of Regulations. There is also a Technical Violation being issued during this visit.

An exit interview was conducted with Ngoc Mai. This report was reviewed with the administrator and a copy was provided at the end of the visit. Appeal Rights were reviewed.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC809 (FAS) - (06/04)
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