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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005470
Report Date: 04/26/2022
Date Signed: 04/26/2022 01:24:46 PM


Document Has Been Signed on 04/26/2022 01:24 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:
04/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ngoc "Nick" MaiTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts Michelle Reed and Edward Tapia conducted a visit to discuss Complaint # 22-AS-20220421083332. During the visit, LPAs noted the following

Staff #1 was not fingerprint cleared or associated to the facility and has been working for at least a month. The common bathroom is also under construction and all residents are being showered in the master bedroom that is being occupied by Resident #3.

See LIC 809D for cited deficiencies.

An exit interview was conducted and a copy of this report and appeal rights were given to Ngoc Mai.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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 2


Document Has Been Signed on 04/26/2022 01:24 PM - 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: GRACES HOME
FACILITY NUMBER: 306005470

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2022
Section Cited

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Criminal Record Clearance-All individuals subject to a criminal record review shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption (2) Request a transfer of a criminal record clearance. This requirement was not met as evidence by;
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Staff #1 has been working at the facility for approximately 1 month and does not have a criminal record clearance through the Department.
This poses an immeidate health and saftey risk to residents in care.
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Type B
05/10/2022
Section Cited

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Personal Accomations and Services- Resident bedrooms shall meet the following requirements; No bedroom of a resident shall be used as a passageway to another room, bath or toilet.
This requirement was not met as evidenced by
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Residents are being showered in the master bedroom that is being occupied by Resident #3.
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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: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2