<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800447
Report Date: 05/02/2022
Date Signed: 05/02/2022 11:37:30 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/26/2022 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220426160743
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: 5DATE:
05/02/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:
Rholet Miller, Caregiver		TIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Not enough staff to meet residents' needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Amy Goldenberg is conducting this unannounced visit for the purpose of initiating investigation into the above mentioned complaint allegation.

This investigation consisted of interviews with five (5) residents, two (2) staff and review of the staffing schedule for April 2022. Investigation revealed the following: LPA observed two staff assisting residents during this visit. Two (2) of two (2) staff interviewed report there are always two on the shift. Staffing schedules reviewed revealed that two staff are scheduled each shift. There are currently five (5) residents in the home. Four (4) out of five (5) residents interviewed report that their needs are being met by staff. One (1) of five (5) residents interviewed reports that they would like a nurse to be at the facility, but reports that a nurse comes in to provide care to them.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20220426160743
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 INC
FACILITY NUMBER: 331800447
VISIT DATE: 05/02/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on the information available, we have found the complaint allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2