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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800157
Report Date: 09/19/2022
Date Signed: 09/19/2022 04:16:01 PM

Document Has Been Signed on 09/19/2022 04:16 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:
09/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Administrator, Nkechi AnwuliTIME COMPLETED:
04:25 PM
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Licensing Program Anaylst (LPA) Janira Arreola along with Licwensing Program Manager (LPM) Joel Esquivel made an unannounced visit to the facility to cite deficiency observed. LPA met with Administrator Nkechi Anwuli who was informed of the purpose of the visit.

LPA took a tour of the interior and exterior of the facility. LPA observed unlocked chemicals under the sink and well as unlocked knifes in the kitchen of the facility. LPA asked staff why it was unlocked, and staff stated that they were getting a spoon out to give to a resident. Staff locked the cabinet in front of LPA. This posed a risk to residents in care.

LPA further found in Resident 1 (R1)'s room had a door that was unlocked leading to the facility garage. LPA observed unlocked laundry detergent on top of the facility washer accessible to R1. This poses a risk to residents in care.

In the facility living room, LPA observed that the file cabinets used to house client medications were unlocked. This poses a risk to clients in care.

The above deficiencies were cited in an LIC809-D page along with Plan of corrections.

An exit interview was conducted where this report was reviewed along with LIC809-D pages and appeal rights. These were provided to Administrator, Nkechi Anwuli.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2022
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 3
Document Has Been Signed on 09/19/2022 04:16 PM - It Cannot Be Edited


Created By: Janira Arreola On 09/19/2022 at 03:35 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACE VILLA
FACILITY NUMBER: 331800157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2022
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirment was not met as evidenced by:
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Licensee ensure the door leading to garage connected to R1's room is locked at all times. Licensee is to submit photo proof of this to LPA by POC date.
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LPA observed unlocked cleaning chemicals in facility garage that were made accessible to clients in care. LPA also found that the cleaning chemicals in the kitchen and sharp knifes were unlcoked. This psoes an immediate personal rights, health, or saftey risk.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/19/2022 04:16 PM - It Cannot Be Edited


Created By: Janira Arreola On 09/19/2022 at 03:39 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACE VILLA
FACILITY NUMBER: 331800157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2022
Section Cited
CCR
80075(k)(1)

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80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible...
This requirment was not met as evidenced by:
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Licensee will ensure that these file cabinets are locked at all times. Licensee will submit proof of the cabinets locked by the POC date.
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LPA observed that the medications being kept in the file cabinets in the facility living room were unlocked and made accessibel to clients in care. This poses a potential personal rights, health or saftey risk to residents in care.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022


LIC809 (FAS) - (06/04)
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