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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005470
Report Date: 09/26/2024
Date Signed: 09/26/2024 04:23:45 PM

Document Has Been Signed on 09/26/2024 04:23 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:
09/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Quy "Anna" MaiTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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 Caregiver (CG) Quy "Anna" Mai and discussed purpose of today's case management visit - Deficiencies visit. Administrator Ngoc "Nick" Mai was not present but LPA spoke to AD Mai over the phone.

During the visit LPA Tea was greeted and granted entry by a new staff, Sau Nguyen. LPA observed that AD was not present and just the staff was alone with the residents at the facility. LPA was able to talk to AD Mai over the phone and asked where he was. AD Mai said he is far away from the facility in San Bernardino obtaining cooking utensils for the facility and that the residents are being supervised by the present staff who is AD Mai's cousin, who he plans to hire as a caregiver for the facility. AD Mai said that he was testing him out with the residents. LPA Tea asked AD Mai if he had the staff fingerprinted and passed background clearance. AD Mai said he just started the paperwork. LPA explained that all staff whether test trial or not is required to have full background clearance to be at the facility. AD Mai understood and said that he will have his sister, Quy "Anna" Mai an on-call caregiver come to facility within in half an hour.

LPA observed there is not enough staff to care for residents, especially when AD Mai is away.

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 deficiencies.

An exit interview was conducted with Caregiver staff Quy "Anna" Mai and Administrator Nick Mai over the phone a copy of this report LIC809 and LIC809D and appeal rights were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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 09/26/2024 04:23 PM - It Cannot Be Edited


Created By: Michael Tea On 09/26/2024 at 02:29 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACES HOME
FACILITY NUMBER: 306005470

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2024
Section Cited
CCR
87355(e)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
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Licensee will have proof that staff obtain fingerprint and be background cleared in order to work and be at the facility by POC due date.
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Based on LPA's observation, new staff does not have background clearance to be at the facility. This poses an immediate health and safety risk to residents in care.
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Type A
09/27/2024
Section Cited
CCR87405(a)

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Administrator - Qualifications and Duties ... facilities shall have a qualified and currently certified administrator. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section.
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Licensee to provide a written statement of understanding of the regulation and forward to LPA by POC due date.
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This requirement is not met as evidenced by:

Based on LPA's observation, facility lacks enough staffing and back up administrator while away, which poses an immediate health and safety risk to residents in care.
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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 Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/26/2024 04:23 PM - It Cannot Be Edited


Created By: Michael Tea On 09/26/2024 at 03:24 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACES HOME
FACILITY NUMBER: 306005470

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2024
Section Cited
CCR
87211(a)(1)

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Reporting Requirements ... (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to ...

This requirement is not met as evidenced by:
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Licensee to provide a written statement of understanding of the regulation and forward to LPA by POC due date.
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Based on LPA's observation, licensee can not recall if the incident on 02/01/2023 was reported to CCLD. LPA searched past SIRs during the time of incident and there is no LIC624 reporting the incident from the facility.
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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 Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
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