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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800157
Report Date: 10/21/2022
Date Signed: 10/21/2022 11:29:03 AM

Document Has Been Signed on 10/21/2022 11:29 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, 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:
10/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Nkechi 'Grace' AnwuliTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to follow up on an incident report received on June 23, 2022. The LPA met with Administrator, Nkechi 'Grace' Anwuli and informed her of the purpose of her visit.

The Department received an incident report from the Inland Regional Center (IRC) detailing an altercation between a staff and client in care. The report indicates that on June 19, 2022, Staff One (S1) arrived at the facility and spoke to Client One (C1) about a prior incident. The report states C1 pulled S1's hair, S1 then pulled the client's hair, they both ended up on the floor, and another staff, Staff Two (S2), had to de-escalate the situation.

Interviews were conducted, records were review, and copies of pertinent documentation were obtained. Administrator Anwuli reported she was informed by staff of the incident the same day it occurred. She stated S1 was suspended and has not returned to the facility. According to the report, C1 sustained an injury to their lip after the client bit them self. Per the Administrator, C1 bit them self due to talking quickly. Client interviews could not be conducted, due to no clients being present at time of visit. Additional time is required, prior to the conclusion of this investigation, in order to conduct further interviews.

During this visit the LPA observed the following violations: failure to report the June 19, 2022 incident to appropriate agencies, a lock on the only exterior exit (facility has no approval for secured perimeter), dirty base boards and shower in the hall bathroom and floor boards in the kitchen were worn and missing one piece. These violations pose an immediate and potential threat to the health, safety and personal rights of the clients in care.

An exit interview was conducted with Anwuli; this report was reviewed, and a copy provided, along with LIC 9099D, LIC 811, LIC 421IM, and Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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Document Has Been Signed on 10/21/2022 11:29 AM - It Cannot Be Edited


Created By: Stephanie Torres On 10/21/2022 at 09:15 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACE VILLA
FACILITY NUMBER: 331800157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2022
Section Cited
CCR
80020(a)(2)

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FIRE CLEARANCE: All facilities shall secure & maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. Prior to the use of secured perimeters, an applicant or licensee for an ARF...shall meet the fire clearance approval
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The lock was immediately removed. The administrator agreed to providing a statement ensuring a lock will not be placed on any exit doors unless approval is received.
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requirements of Title 17, Division 2, Chapter 3, Subchapter 4, Article 12, Section 56072(d) & (h). This requirement was not met as evidenced by: Based on observation, the Licensee did not abide by the section cited above. A lock was observed on the only exterior exit gate.
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Type B
11/04/2022
Section Cited
CCR80087(a)

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BUILDINGS AND GROUNDS: The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by: Based on observation the licensee did not abide by the section cited above.
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Administrator stated photos will be submitted once the hall bathroom is cleaned and floor boards replaced.
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The LPA observed dirty base boards and shower in the hall bathroom and the floor boards in the kitchen are worn and missing one piece.
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Stephanie Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/21/2022 11:29 AM - It Cannot Be Edited


Created By: Stephanie Torres On 10/21/2022 at 10:01 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACE VILLA
FACILITY NUMBER: 331800157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2022
Section Cited
CCR
80061(d)

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REPORTING REQUIREMENTS: Any suspected physical abuse that does not result in serious bodily injury of a...dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, & the local law enforcement agency within 24 hours as required by W&I Code Section 15630(b)(1).
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The Administrator agreed to submit a SOC 341 to CCL and local law enforcement.
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This requirement was not met as evidenced by: Based on interviews, the Licensee did not abide by the section cited above. The Administrator report the incident on 06/19/22 was not reported to local law enforcement. She also stated that CCL was notified via fax, however, the number listed was incorrect.
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Stephanie Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022


LIC809 (FAS) - (06/04)
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