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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005470
Report Date: 02/07/2023
Date Signed: 02/07/2023 05:01:46 PM


Document Has Been Signed on 02/07/2023 05:01 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: 4DATE:
02/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Nick Mai, Licensee/AdministratorTIME COMPLETED:
05:01 PM
NARRATIVE
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted this case management- Deficiencies visit in conjunction to the 10 day visit for Complaint Control#22-AS-20230203140953.
LPA Quiroz met with Licensee/Administrator (L/AD) Ngoc "Nick" Mai and discussed purpose of today's case management visit- Deficiencies visit.
During 10 day visit for complaint control#22-AS-20230203140953, LPA Quiroz along with (L/AD)Ngoc "Nick" Mai took a tour of the physical plant of the facility interior and exterior of facility premises. Between 9:53am-12:50pm, 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 9:53 am-12:50pm, LPA Quiroz observed uncleaned stove with grease stains, food with no label dates, food and trash particles throughout the kitchen area, living room area, common living areas, pair of scissors, diabetic used lancet in kitchen dining-room. LPA Quiroz observed gardening tools varying in sizes from small to large, 2 paint containers, automobile door white in color in backyard area readily available to residents in care. LPA Quiroz observed outdoor and indoor passageways obstructed throughout the garage and in staff office area. This was verified with (L/AD) Mai indicating understanding the risk to residents in care.
During today's visit, LPA Quiroz conducted interviews with interviewees and reviewed 4 of 4 resident's records. During today's record review, LPA Quiroz did not observe physician reports on file for Resident 1 (R1) and Resident 2 (R2). During today's record review but not limited to Discharge paperwork from UCI Medical Center for R1, LPA Quiroz observed resident was tested positive for COVID-19 during admission and discharge. FAS records indicate no COVID-19 positive reporting to Community Care Licensing (CCL). This was verified with (L/AD) Mai indicating " I thought the pandemic was over. I forgot."
Based on this inspection, multiple deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. (See LIC 809-D pages for deficiencies). Civil Penalties were also assessed during today's visit. This report was reviewed with (L/AD) Mai and a copy of this report LIC 809, LIC 809-D pages, LIC 811- Confidential Names, LIC 421 IM-CIVIL PENALTY ASSESSMENTS – IMMEDIATE $500 AND REPEAT VIOLATIONS and Appeal Rights were provided to (L/AD) Mai at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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


Document Has Been Signed on 02/07/2023 05:01 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: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2023
Section Cited

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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...
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L/AD Mai removed pair of scissors in kitchen area and diabetic lancet from diningroom table. 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 2/8/2023. AD removed lancet and scisscors. Corrected during visit.
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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 9:53am-12:50pm, LPA Quiroz observed pair of scissors in kitchen area, diabetic CONT...
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used lancet on diningroom table. This poses an immediate risk to residents in care.
Type A
02/07/2023
Section Cited

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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
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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 2/10/2023.
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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: window panels, gardening tool items varying in sizes from small to large, unused items,gallons of paint CONTINUED...
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in backyard area and automobile door white in color. This was verified with L/AD Mai. This poses an immediate 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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 02/07/2023 05:01 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: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited

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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...
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LPA Quiroz provided Licensee with CCR 87303 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
Upon arrival to the facility, Caregiver 1 assisted with cleaning of kitchen area. This poses a potential risk to residents in care
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This requirement is not being met as evidenced by, between 9:53am-12:50pm 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 CONT...
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CONT... LPA Quiroz observed food in the refrigerator area not labeled, trash particles through out living room and kitchen area a This poses a potential risk to residents in care.
Type A
02/10/2023
Section Cited

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False Claims 87207: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was met as evidenced by: Upon arrival to facility, L/AD Mai CONTINUED...
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L/AD Mai will read and understand CCR 87207 False Claims and submit proof of understanding to CCL by 2/8/2023.
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CONT...indicated Caregiver had just left to go get bread to eat. During interview conducted with caregiver, Caregiver indicated she had not been present at facility since 2/2/23. This was verified with L/AD Mai. This poses an immediate 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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 02/07/2023 05:01 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: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2023
Section Cited

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(b) Each resident’s record shall contain at least the following information:(10)Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions.This requirement was not met as evidenced by:
During today's record review CONT...
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L/AD Mai agreed to call physician for R2 and receive copy of updated physician report and submit to CCL by 2/7/2023 and agreed to call and schedule an appointment for R1 and have medical report completed by 2/8/2023.
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LPA Quiroz did not observe physician reports for R1 and R2. This was verified wtih L/AD Mai who indicated not having physician reports for R1 and R2 indicating they were admitted without a physician report. This poses an immediate risk for residents in care.
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Type A
02/08/2023
Section Cited

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Reporting Requirements-87211(a)(2)
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(2) Occurrences, such as epidemic outbreaks...which threaten the welfare, safety or health CONT...
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 L/AD Mai agreed to read and understand CCR 87211 and submit proof of understanding. lpa Quiroz will call OCPH and report positive case and submit COVID-19 Covid script to CCL by 2/7/2023 COB.
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of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by: During today's record review for R1, LPA Quiroz observed resident's discharge
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paper work from UCI Medical center indicating covid positive status upon admission and discharge. This was verified with L/AD Mai indicating he forgot to report to OCPH and CCL. This poses an immediate 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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4