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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880716
Report Date: 06/14/2023
Date Signed: 06/14/2023 12:30:36 PM


Document Has Been Signed on 06/14/2023 12:30 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:GRACIOUS CARE INC #2FACILITY NUMBER:
331880716
ADMINISTRATOR:NA ZHAOFACILITY TYPE:
740
ADDRESS:14598 STONYBROOK CTTELEPHONE:
(951) 372-0694
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 5DATE:
06/14/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Brandon Marquez-GutierrezTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Regional Manager (LPRM) Leslie Mendiveles, Licensing Program Manager (LPM) Efren Malagon, and Licensing Program Analyst (LPA) Ryan Gardner conducted an announced office visit. LPRM, LPM, and LPA met with Administrator Brandon Marquez-Gutierrez and explained the reason for the visit.

During a facility file review, LPA discovered that the facility is past due in licensing fees in the amount of $495.00. The full amount due is required to be paid by 6/23/2023.

During today’s office visit, the licensee agreed to ensure there is an administrator present in the facility for enough hours to adequately manage the facility. The licensee agreed to send state licensing updated LIC500, LIC308, and LIC309 by 6/19/2023.

Based on findings today, the facility will be issued one (1) type B deficiency per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Brandon Marquez-Gutierrez, along with a copy of LIC809D and the appeal rights.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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 06/14/2023 12:30 PM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GRACIOUS CARE INC #2
FACILITY NUMBER: 331880716

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
87156(a)

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87156 Licensing Fees(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.
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The licensee has agreed to read regulation 87156 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to pay the amount due by POC due date. POC due date is 6/23/2023.
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Based on interview, record review, and observation the licensee did not comply with the section cited above evidenced by a past due amount of $495.00 in licensing fees which poses a potential health, safety or personal rights risk to persons 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: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2