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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800157
Report Date: 11/01/2021
Date Signed: 11/01/2021 03:04:19 PM

Document Has Been Signed on 11/01/2021 03:04 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GRACE VILLAFACILITY NUMBER:
331800157
ADMINISTRATOR:ANWULI, NKECHIFACILITY TYPE:
735
ADDRESS:22699 KINROSS LANETELEPHONE:
(951) 419-0024
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 4DATE:
11/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Caregiver, Osseh GipsonTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) David Cuevas made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by, caregiver, Ms. Gipson and explained the purpose of the visit. At the time of visit there were 2 staff and 4 residents present. The facility currently has zero positive or suspected Covid-19 cases. No pools or bodies of water in premises, LPA was informed that no weapons or ammunition is maintained at the home.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer) in all restrooms.

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility also has a designated infection control lead and cleans and disinfects the highly touched surfaces during each shift, and as needed.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to caregiver, Osseh Gipson who was authorized by Licensee to sign for report.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2021
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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