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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800447
Report Date: 04/05/2022
Date Signed: 04/05/2022 11:31:07 AM


Document Has Been Signed on 04/05/2022 11:31 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
, CA 92507



FACILITY NAME:GRATEFUL HEART HOME CARE INCFACILITY NUMBER:
331800447
ADMINISTRATOR:UY, CHARMAINEFACILITY TYPE:
740
ADDRESS:14223 POINTER LOOPTELEPHONE:
(951) 427-1800
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 6DATE:
04/05/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rholet Miller, CaregiverTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Amy Goldenberg arrived unannounced to the facility for the purpose of a Plan of Correction (POC) visit. On 3/23/22 the facility was issued a deficiency with a plan of correction. Licensee was to provide access to the locked space in the facility by POC due date along with submission of a statement of understanding of section cited by POC due date. LPA received the statement of understanding on 3/24/22. During this visit LPA is conducting a physical plant assessment of the plan of correction. LPA was granted access to the storage space in the garage and has determined that the plan of correction has been met.

This report was reviewed with and a copy was provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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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