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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005674
Report Date: 09/02/2022
Date Signed: 09/02/2022 03:42:11 PM

Document Has Been Signed on 09/02/2022 03:42 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:GRACE HILLS HOME CAREFACILITY NUMBER:
306005674
ADMINISTRATOR:RADFORD, GRACEFACILITY TYPE:
740
ADDRESS:24582 VANESSA DRIVETELEPHONE:
(949) 939-3733
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
09/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Grace Radford, AdministratorTIME COMPLETED:
03:55 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 09/02/2022 at 2:45pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection focusing on Infection Control procedures. LPA was greeted and granted entry by Administrator Grace Radford and explained the purpose of the visit.

At approximately 3:00pm, LPA accompanied by administrator toured the physical plant of the facility. There are currently four (4) residents in care, two (2) of which are receiving hospice care. The residents are observed relaxing in their respective bedrooms and appear clean and well taken care of. The bedrooms include all necessary components. An ample supply of linen is observed. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected.

Sharp instruments are stored in a kitchen drawer secured by a child-proofing lock. The centrally stored medication are located in the staff bedroom in a locked cabinet. Cleaning supplies are located in the garage and under the kitchen sink and are secured. LPA observed a sufficient supply of food and water present, including emergency water and rations.

LPA observed the facility has COVID-19 Precautions posters and all required department postings. Staff present is adequately cleared and associated in Guardian. The fire extinguisher present is mounted and charged. Service dates are up-to-date.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2022
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
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: GRACE HILLS HOME CARE
FACILITY NUMBER: 306005674
VISIT DATE: 09/02/2022
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
CONTINUED FROM FORM LIC809

LPA and administrator toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture is present for the enjoyment of residents and visitors. The perimeter gates are self-latching and can easily be opened in an evacuation. There is a swimming pool in the backyard with adequate fencing and a locked gate.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2