306005470-10-26-2022-22-AS-ETAA-CKKRCF-20221026125416

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005470
Report Date: 10/26/2022
Date Signed: 10/26/2022 12:54:30 PM

Document Has Been Signed on 10/26/2022 12:54 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 HOME		FACILITY NUMBER:	306005470
ADMINISTRATOR:	MAI, NGOC		FACILITY TYPE:	740
ADDRESS:	2152 S JETTY DR		TELEPHONE:	(714) 553-1166
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY:	6	CENSUS: 3	DATE:	10/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:26 AM
MET WITH:	Ngoc "Nick" Mai		TIME COMPLETED:	01:10 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

Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Administrator Nick Mai and stated the purpose of this visit.

The facility is a single level structure and licensed for six non-ambulatory of which two may be bedridden with a hospice waiver for six. This facility is a Residential Care Facility for the Elderly/Dementia.

At about 11: 26 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 3 residents in care and Administrator on duty. LPA toured the interior and exterior portions of the facility. There were 3 resident rooms 2 of which had the potential of being shared rooms. One room is vacant and used for storage. Facility had a staff room which is kept inaccessible to residents. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 114.8 degrees Fahrenheit. LPA noticed cleaning supplies in one of the restrooms. Administrator immediately removed cleaning supplies from residents in care. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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 4

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
	VISIT DATE: 10/26/2022

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
26
27
28
29
30
31
32

For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA noticed tools, supplies for the home throughout the backyard and no adequate shading for the outdoor patio. Administrator states the residents do not come out to the backyard. Administrator was made aware of proper shading and home supplies needing to be inaccessible to residents in care. Administrator agreed to have everything cleared out in a week. Facility offers a 2-car garage which is used for storage with an operational washer/dryer and a staff refrigerator. Kitchen was kept clean with medications kept locked and sharp items were inaccessible to residents in care. Administrator was made aware of annual fee due on 11/14/2022. Administrator stated they will pay annual fee prior to due date.

LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. Two advisories were issued today.

LPA Tapia conducted an exit interview with Administrator Nick Mai and a copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4