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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800447
Report Date: 12/15/2023
Date Signed: 12/15/2023 10:39:43 AM


Document Has Been Signed on 12/15/2023 10:39 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:
12/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Linda Tatofi, CaregiverTIME COMPLETED:
11:00 AM
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
Licensing Program Analyst (LPA) Amy Goldenberg is conducting this case management visit to address deficiencies in conjunction with complaint control number 18-AS-20220118141100 which were discovered through investigation that were not part of the initial allegations. The facility failed to meet the reporting requirement regarding R1's fall on 10/14/2021 and subsequent death within the regulatory time frame.

See LIC908D for deficiency cited. This report was reviewed with 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: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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 2


Document Has Been Signed on 12/15/2023 10:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2023
Section Cited
CCR
87211(a)(1)

1
2
3
4
5
6
7
A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...
1
2
3
4
5
6
7
Licensee to conduct training with all employees in reporting requirements and submit a statement of understanding of regulation section cited along with staff inservice sign in sheet.
8
9
10
11
12
13
14
The facility failed to meet the reporting requirement regarding R1's fall on 10/14/2021 and subsequent death within the regulatory time frame.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2