<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005470
Report Date: 11/14/2022
Date Signed: 11/14/2022 02:06:48 PM

Document Has Been Signed on 11/14/2022 02:06 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:GRACES HOMEFACILITY NUMBER:
306005470
ADMINISTRATOR:MAI, NGOCFACILITY TYPE:
740
ADDRESS:2152 S JETTY DRTELEPHONE:
(714) 553-1166
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 3DATE:
11/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Ngoc "Nick" Mai, Licensee/AdministratorTIME COMPLETED:
02:04 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted this case management in conjunction to the 10 day visit for Complaint Control #:22-AS-20221110131242. LPA Quiroz met with Licensee/Administrator (L/AD) Ngoc "Nick" Mai and discussed purpose of today's case management visit- Deficiencies visit.

During the visit LPA Quiroz along with Licensee Administrator Ngoc "Nick" Mai took a tour of the physical plant of the facility indoor and exterior of facility premises. Between 10:13am-10:42am, LPA Quiroz inspected resident’s bedrooms, kitchen area, garage area, back yard area and all common areas in the facility. During today's facility tour inspection between 10:13 am-10:42am, LPA Quiroz observed medications with label and no label in kitchen area and in Resident 4 (R4) bedroom area, uncleaned stove with grease stains, food with no label dates, spider webs, food and trash particles throughout the kitchen area, living room area, common living areas, soiled clothes in Resident's 3 bathroom area, bottles of wine in refrigerator, scissors, four knives on kitchen counter/sink area readily available to residents in care. This was verified with (L/AD) Mgoc Mai. (L/AD) Mai indicated "I understand the risk."


Based on this inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiencies. A Civil Penalty was also assessed during today's visit.

This report was reviewed with (L/AD) Ngoc Mai and a copy of this report LIC 809, LIC 809-D pages, LIC 811- Confidential Names, LIC 421 IM-CIVIL PENALTY ASSESSMENT – IMMEDIATE $500 AND REPEAT VIOLATIONS and Appeal Rights were provided to (L/AD) Ngoc Mai at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2022
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 11/14/2022 02:06 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 11/14/2022 at 11:10 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: 11/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2022
Section Cited
CCR
87705(f)(1)(2)

1
2
3
4
5
6
7
87705(f)(1)(2):Care of Persons With Dementia(f) the following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools, and other items that could constitute a danger to the resident(s). (2) OTC medication, supplements or vitamins, alcohol, cigarettes & CONTINUE...
1
2
3
4
5
6
7
L/AD Mai removed knives, alcohol and over the counter medication during today's visit. LPA Quiroz provided L/AD Mai with copy of CCR 87705. L/AD Mai will read and agree to understanding of CCR 87705 and provide training to staff listed on LIC 500 by POC deadline of 11/15/2022.
8
9
10
11
12
13
14
CONT...toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by while LPA Quiroz conducted tour along with L/AD Mai between 10:13am-10:42am, LPA Quiroz observed knives, scissors, OTCmedications and R4's medication in bedroom area CONT...
8
9
10
11
12
13
14
CONT...Medication in kitchen area observed to be without name label and bottle of wine in refrigerator area.This was verified with L/AD Mai throughout facility inspection visit. This poses an immediate risk to residents in care. CIVIL PENALTY ASSESSED.
Type B
11/15/2022
Section Cited
CCR87303(a)(1)

1
2
3
4
5
6
7
Maintenance and Operation (87303)(a)(1):
(a) The facility shall be clean, safe, sanitary and in good repair at all times... for the safety and well-being of residents, employees and visitors.(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. CONTINUED...
1
2
3
4
5
6
7
LPA Quiroz printed CCR 87303 and provided copy to L/AD Mai. L/AD Mai will read and agree to understanding of CCR 87303 and provide training to staff listed on LIC 500
(L/AD) Mai indicated "I will clean all areas" by 11/18/2022.
8
9
10
11
12
13
14
This requirement is not being met as evidenced by, between 10:13am-10:42am while LPA Quiroz toured facility along with L/AD Mai, LPA Quiroz observed food particles and grease stains on the kitchen stove, kitchen counters, sink area and food crumbs on the kitchen floor area CONTINUED...
8
9
10
11
12
13
14
CONT... LPA Quiroz observed food packaged not labeled on kitchen counter and in the refrigerator area not labeled, spider webs and trash particles through out living room, kitchen area and uncleaned bathroom with soiled clothes in R3's bedroom area. This poses a potential risk to residents in care.
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:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/14/2022 02:06 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 11/14/2022 at 11:57 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: 11/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited
CCR
87307(d)(6)

1
2
3
4
5
6
7
87307(d)(6)Personal Accommodations and Services(d)The following space and safety provisions shall apply to all facilities:(6)All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: While LPA Quiroz toured facility along CONT
1
2
3
4
5
6
7
LPA Quiroz printed and provided copy of CCR 87307 to (L/AD) Mai. (L/AD) will read and understand and provide training to staff listed on LIC 500 (Personnel Report) and agreed to clean garage and back yard area by POC due date of 11/18/2022.
8
9
10
11
12
13
14
with L/AD Mai, LPA Quiroz observed excessive amount of storage items in garage area and back yard east side location of facility premises but not limited to: Toilets, sinks, window panels, tool items, unused items, CONTINUED...
8
9
10
11
12
13
14
CONT...This was verified with (L/AD) Mai indicating "Yeah, I need to clean it up and take it to my moms place." This poses an immediate risk to residents in care.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3