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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800157
Report Date: 11/05/2024
Date Signed: 11/05/2024 11:58:54 AM

Document Has Been Signed on 11/05/2024 11:58 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GRACE VILLAFACILITY NUMBER:
331800157
ADMINISTRATOR/
DIRECTOR:		ANWULI, NKECHIFACILITY TYPE:
735
ADDRESS:22699 KINROSS LANETELEPHONE:
(951) 419-0024
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Nkechi Anwuli- AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Debbie Palacios made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Administrator Nkechi Anwuli who was informed of the purpose of the visit. Administrator Anwuli informed LPA that three (3) clients were attending day program; one (1) client was present at the facility. The facility has a fire clearance for six (6) ambulatory clients and serves adults ages 18 through 59.

LPA toured the facility and reviewed records. During the tour, LPA observed the facility is made up of a one (1) story home with four (4) client bedrooms, two (2) bathrooms, a living room, dining room and a garage. . All client bedrooms had the required furniture and lighting. LPA toured the facility's exterior and observed outdoor pathways were free of obstructions. Outdoor shaded seating area is available for the clients in care. LPA observed a hallway cabinet filled with clean towels, blankets, and linen, available for the clients. LPA toured the kitchen and observed the facility has a 2-day supply of perishable foods and more than a 7-day supply of non-perishable foods, which are stored in a safe and healthful manner. The garage has an extra refrigerator with non- perishable foods. LPA observed knives and sharp instruments secured in locked kitchen cabinets. Cleaning solutions and disinfectants are secured in a lock cabinet in the garage. Administrator Anwuli tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed two (2) charged fire extinguishers mounted throughout the facility dated 09/18/24. Medications are secured in a locked cabinet stored in the living room. LPA reviewed the Medication Administration Record along with the physical medications for two (2) clients and did not discover any discrepancies. LPA reviewed random client files and observed clients had updated Individual Program Plans and signed admission agreements.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GRACE VILLA
FACILITY NUMBER: 331800157
VISIT DATE: 11/05/2024
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 LPA reviewed the Record of Client's/Resident's Safeguarded Cash Resources (LIC 405) and Administrator Anwuli reviewed the physical monies for one (1) client, and no discrepancies were discovered. Exit signs, emergency contact information, client's personal rights, and complaint information are visibly posted near the entrance hallway.


During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Anwuli.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
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