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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005470
Report Date: 09/11/2024
Date Signed: 09/11/2024 10:46:00 AM


Document Has Been Signed on 09/11/2024 10:46 AM - 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:MAI, NGOCFACILITY TYPE:
740
ADDRESS:2152 S JETTY DRTELEPHONE:
(714) 553-1166
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:6CENSUS: 4DATE:
09/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Ngoc "Nick" MaiTIME COMPLETED:
11:00 AM
NARRATIVE
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On today's date, Licensing Program Analyst (LPA) Michael Tea conducted this case management in conjunction with the continued Complaint visit Control #:22-AS-20230203140953. LPA Tea met with Administrator (AD) Ngoc "Nick" Mai and discussed purpose of today's case management visit - Deficiencies visit.
During the visit LPA Tea while reviewing resident records discovered Resident 1(R1) Physician report to be outdated and has a diagnosis of dementia. Residents with dementia are suppose to have updated physician's report annually.
Based on this inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for the deficiency.

An exit interview was conducted with Administrator Nick Mai a copy of this report LIC809 and LIC809D and LIC811 and appeal rights were provided at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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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Document Has Been Signed on 09/11/2024 10:46 AM - 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
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: 09/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2024
Section Cited
CCR
87705(c)(5)

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"Care of Persons with Dementia" ... Each resident with dementia shall have an annual medical assessment ... done at least annually ... of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidence by:
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Licensee will obtain updated physician's report by COB of POC due date 10/02/24.
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Based on LPA's review of resident records, LPA discovered outdated Physician Report sign and dated by Physician 02/17/2023.
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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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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