306006127-9-29-2023-22-AS-DLMN-CW5RAJ-20230929125113

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006127
Report Date: 09/29/2023
Date Signed: 09/29/2023 12:52:13 PM

Document Has Been Signed on 09/29/2023 12:52 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	GRACIE'S GUEST HOME		FACILITY NUMBER:	306006127
ADMINISTRATOR:	AZNAR, MARY GRACE		FACILITY TYPE:	735
ADDRESS:	13292 SIEMON AVE		TELEPHONE:	(714) 727-8741
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92843
CAPACITY: 6		CENSUS: 6	DATE:	09/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:37 AM
MET WITH:	Jeseca Aznar - Co-Administrator		TIME COMPLETED:	01:15 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 Analysts (LPA) Dwayne Mason Jr. arrived at Gracie’s Guest Home to conduct an unannounced Required 1 Year Inspection. At 8:30am, LPA was greeted and granted entry by Caregiver Luzviminda "Tom" Perino. Co-Administrator Jeseca Aznar arrived at the facility at approximately 9:00am. Administrator Mary Aznar joined the inspection via phone call throughout the visit. Upon record review LPA noted that the facility’s annuals fees are not current, one employee does not have a verifiable criminal record clearance and one employee is not associated with the facility. Three deficiencies are being given on this day. Structure: The facility is a one-story home with three shared resident bedrooms, two bathrooms, living room, kitchen, dining room, two staff bedrooms, an attached two car garage and backyard. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the dining room area. There is a back yard with one exit gate on each side of the house. There is a shaded seating area in the backyard. The facility also has a tortoise pen, coi fish pond and chicken coop in the backyard. Co-Administrator stated some residents help with feeding and caring for the animals if they so choose. LPA also observed a lounging area in the front yard of the house. This area has shaded seating areas and is fenced in. There is an unlocked gate leading from the front yard to the driveway. LPA did not observe any obstacles or hazards in either the front or backyard. Upon review of the approved facility sketch, LPA observed a room designated to be a non-ambulatory resident room to be a staff room. A deficiency is being given on this day. Client Bedrooms All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPA observed all windows were screened. All bedrooms have alarmed doors leading outside Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked beneath the kitchen sink and in the garage.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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 5

Document Has Been Signed on 09/29/2023 12:52 PM - It Cannot Be Edited

Created By: Dwayne L Mason On 09/29/2023 at 10:31 AM

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: GRACIE'S GUEST HOME	FACILITY NUMBER: 306006127
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as LPA confirmed the Co-Administrator does not have a criminal record clearance. This poses an immediate safety risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Administrator and co-Administrator will contact Guardian via phone call to verify criminal record clearances for all facility staff by the assigned due date. Facility will provide LPA with proof of clearances for all employees via email by the assigned POC due date of 10/02/2023. Any staff whose clearances cannot be verified will submit a new criminal record clearance and provide LPA with proof of submission via email by the assigned due date of 10/02/2023.

Type A

Section Cited

CCR

80019(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as one employee's association with the facility could not be verified via the Licensing Information System (LIS). This poses an immediate safety risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Administrator and Co-Administrator will contact Guardian via phone call to associate all facility staff by the assigned due date. Facility will provide LPA with a copy of all employees association status via email by the assigned POC due date of 10/02/2023

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Dwayne L Mason

LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 09/29/2023 12:52 PM - It Cannot Be Edited

Created By: Dwayne L Mason On 09/29/2023 at 11:28 AM

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: GRACIE'S GUEST HOME	FACILITY NUMBER: 306006127
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(a)

Fire Clearance

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and facility sketch, the licensee did not comply with the section cited above as a room designated for non-ambulatory residents was being used as a staff room and vice-versa. This poses an immediate safety risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Co-Administrator contacted staff to swap all items in the two rooms in question. Staff swapped the two rooms during the LPA's inspection. LPA verified the facility is adhering to the most current facility sketch during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Dwayne L Mason

LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 09/29/2023 12:52 PM - It Cannot Be Edited

Created By: Dwayne L Mason On 09/29/2023 at 11:47 AM

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: GRACIE'S GUEST HOME	FACILITY NUMBER: 306006127
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80036(a)

An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as the facility has an overdue balance of annual fees and change of location fees. This poses an potential health risk to persons in care as ongoing failure to pay fees can result in facility closure.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	Administrator will mail payment of their balance and notify LPA of the state's receipt of payment by the assigned POC due date of 10/30/23. LPA will verify this plan of correction via the Licensing Information System (LIS) by the assigned POC due date of 10/30/23

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Dwayne L Mason

LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACIE'S GUEST HOME	FACILITY NUMBER: 306006127
	VISIT DATE: 09/29/2023

NARRATIVE

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Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet in the living room. First aid kit is stored mounted on a wall in the dining area. LPA reviewed client medication. Medication appeared to be properly labeled and organized. LPA observed the medication to be administered by the appropriate schedule. LPA also observed the next month’s medication supply to be locked and ready for use beginning 10/01/2023.
Resident & Staff Files: Records are kept locked in the cabinet with the medication. LPA reviewed 3 out of 6 client files and 4 staff files. LPA reviewed Resident cash resources and ledger with Co-Administrator. All resident cash resources were observed to be accurate and accessible to residents as needed.
Fire Extinguisher: The fire extinguishers is fully charged.
Activity Materials: The facility has books, magazines, board games and exercise equipment that will be kept in the living room.
Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 114.8 degrees Fahrenheit in the bathroom located inside the staff room. The water pressure in the northwest bathroom is low. Co-Administrator stated that they have been in communication with a plumber to fix the pressure. The plumber arrived to work on the water pressure during the LPA’s inspection. LPA measured the hot water in the shower in the northwest bathroom which measured at 106.8 degrees Fahrenheit. Co-Administrator also stated that residents are able to use the bathroom located in the staff bedroom when needed as they do not lock that bedroom door. LPA noted no hazards in this staff bedroom.
Linens & Hygiene Supplies: A supply of extra linen was stored in the hallway storage. Extra hygiene supplies are located in a cabinet in the garage
Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review
Food Service: There is a supply of 2-day perishable food and a supply of 7-day of non-perishable food on hand. LPA noted the emergency food supply is located in the garage.
Smoke Detectors: Dual Smoke and carbon monoxide detectors tested operational.
Appliances: Gas 5 burner stove, oven, 2 refrigerators, dish washer, microwave, washer, and dryer are operational.

Based on the observations made during today's visit, four deficiencies and two civil penalties are being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted with Administratore Mary Aznar via phone call and Co-Administrator Jeseca Aznar, and a copy of this report and appeal rights were provided during this visit.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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