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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006127
Report Date: 08/29/2022
Date Signed: 08/30/2022 06:40:09 AM

Document Has Been Signed on 08/30/2022 06:40 AM - 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:GRACIE'S GUEST HOMEFACILITY NUMBER:
306006127
ADMINISTRATOR:AZNAR, MARY GRACEFACILITY TYPE:
735
ADDRESS:132932 SIEMON AVETELEPHONE:
(714) 727-8741
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 6CENSUS: DATE:
08/29/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary Grace Aznar and Chau DoTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator/ Licensee Mary Grace Aznar. An initial application to operate an Adult Residential Facility was received by CCL on 12/21/2021 for a capacity of six non-ambulatory clients. Facility has a covid screening area in the entrance of the facility. LPA observed an ample PPE supply in the facility along with covid precaution postings
LPA Lyman along with Licensee/ Administrator toured the facility at 1:10 PM and observed the following:
Structure: Facility is a one story, 5 bedroom, 2 bathroom house with an attached garage and a white exterior with black trim. The exit gates are closed and unlocked. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Clients: Rooms will be double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All client bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Facility has sanitizer and paper towels in the restrooms. Linens & Hygiene Supplies: Facility has ample bedding and towels for clients in care. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Facility has 2 day perishables and 7 day non-perishables present in facility. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility has secured areas for toxins and sharps in the garage and kitchen. Water Temperature: Tested and recorded between 126.8 and 144.8 degrees F. in facility bathrooms. Emergency Supplies: LPA observed ample emergency food and water in the facility. Medications, First-Aid Kit & Book: First aid kit observed contained all required items including a first aid guide. Medication is stored and locked in a cabinet in the dining room. Facility to use a medication administration record. Client & Staff File: Records are stored in a secured file cabinet in the living room. CONTINUED ON LIC 809C DATED 08/29/2022.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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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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: GRACIE'S GUEST HOME
FACILITY NUMBER: 306006127
VISIT DATE: 08/29/2022
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Reading Material, Games, and Equipment: LPA observed an activity schedule with activities such as exercise and arts and crafts. LPA observed games, toys and books in the facility as well. Backyard: LPA observed a large, backyard with dirt and a chicken coop. Gated front area of facility has multiple shaded areas for relaxing and visitation. Fire Clearance: Approved for six non-ambulatory residents on 07/14/2022.

During the visit, LPA observed the following:
  • One burner on the cook top is inoperable. Please repair/ replace.
  • Water temperature tested between 126.8 and 144.8 degrees F. Please adjust water temperature to be between 105 and 120 degrees F.


Licensee to make corrections by 09/05/2022 and notify LPA when completed.




Component III waived during the visit as Licensee is currently operating another facility. Facility is not ready to be licensed. Licensee to contact LPA when corrections have been made.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC809 (FAS) - (06/04)
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