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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006127
Report Date: 09/24/2024
Date Signed: 09/24/2024 11:11:49 AM

Document Has Been Signed on 09/24/2024 11:11 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/
DIRECTOR:
AZNAR, MARY GRACEFACILITY TYPE:
735
ADDRESS:13292 SIEMON AVETELEPHONE:
(714) 727-8741
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 6CENSUS: 6DATE:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:27 AM
MET WITH:Mary AznarTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Kimberly Lyman is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by staff. Mary Grace Aznar, Administrator, arrived shortly after and met with LPA and LPA explained the nature of the visit. Facility is licensed for six non-ambulatory clients. There is one client present during today's visit. Mary Aznar has an administrator certificate valid until 10/01/2025. Upon entry, facility appears clean, safe and sanitary.
LPA Lyman along with Administrator Aznar toured the facility at 8:49 AM. LPA toured the physical plant, checked food service, and reviewed facility documentation. The home consists of three client bedrooms, one shared bathroom, two staff rooms, one staff bathroom, living room, dining room, and kitchen. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Auditory exit alarms are operational during today's visit. Client bathrooms were checked. Toilets and water faucets worked properly, and shower was free of mold/mildew. Water temperature measured at 106.5 degrees F in facility bathroom. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including thermometer, tweezers and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguisher is fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for clients. Exit gates are unlocked, self latching and operational. LPA observed a chicken coop in the backyard. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. plan is thorough and complete. Facility provided documentation of last fire drill conducted on 09/01/2024 and drills are conducted monthly. Facility provides activities in the form of games and exercise. At 9:30 AM, LPA reviewed six client files and three staff files. Client files contained required documents including admission agreements, physician reports and individual program plans. Staff files reviewed contained required documentation of training and all pertinent paperwork. CONTINUED ON LIC 809C DATED 09/24/2024
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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: 09/24/2024
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All staff have proof of CPR training. At 10:00 AM, LPA reviewed medication storage and administration. Facility uses a medication administration record. Medications are stored in a locked cabinet and are being administered per physician order.



Based on the observations made during today’s visit, NO deficiencies are being cited. This report was discussed with the facility representative and a copy was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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