<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
331880716
Report Date:
10/25/2023
Date Signed:
10/25/2023 02:33:11 PM
Document Has Been Signed on
10/25/2023 02:33 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
CCLD Regional Office
,
1650 SPRUCE ST STE 200 MS29-27
,
CA
92507
FACILITY NAME:
GRACIOUS CARE INC #2
FACILITY NUMBER:
331880716
ADMINISTRATOR:
NA ZHAO
FACILITY TYPE:
740
ADDRESS:
14598 STONYBROOK CT
TELEPHONE:
(951) 372-0694
CITY:
EASTVALE
STATE:
CA
ZIP CODE:
92880
CAPACITY:
6
CENSUS:
5
DATE:
10/25/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:15 AM
MET WITH:
Alba Reynoso, Caregiver
Brandon Marquez, Administrator
TIME COMPLETED:
02:45 PM
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
0900: Licensing Program Analyst (LPA) Amy Goldenberg arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. LPA spoke telephonically with the Licensee. LPA noted upon arrival one caregiver (E1), non- english speaking and five residents present.
0935: LPA Goldenberg reviewed Guardian Roster report and noted that E1 and E2 are Unknown/Volunteer status in Guardian. E1 and E2 are scheduled to work in this home today.
0955: Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPAs observe the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 111 degrees F. Grab bars, non-slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility does not handle resident money.
SUPERVISOR'S NAME:
Nedra Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Amy Goldenberg
TELEPHONE:
(951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE:
10/25/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/25/2023
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
8
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:
GRACIOUS CARE INC #2
FACILITY NUMBER:
331880716
VISIT DATE:
10/25/2023
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
1022: Personnel Records/Training/and Staffing- LPA reviewed (3) employee records. CPR requirements have been met. The facility does not employ enough staff. Upon arrival LPA observed E1 on duty alone. Review of finger print clearance revealed that E1 is cleared as a volunteer only. E2 is also only cleared as a volunteer. E1 and E2 are the scheduled staff for this facility. The facility administrator is not present a sufficient number of hours to maintain the facility as evidenced by lack of maintenance of training records, improper staffing and expired fire extinguisher dated 02/01/2019. Administrator certification is present for administrator on file, Na Zhao expired 03/26/2021.
1118: Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA reviewed five (5) resident records.
1230: Food Service- LPA was present during the lunch time meal. The meal is adequate to meet the nutritional needs of the residents. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand.
LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually, however the last time was on 02/01/2019. The facility is not documenting disaster drills.
1244: LPA began preparation of report for delivery. Based on the information received during this visit today, the following deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.
This report was reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.
SUPERVISOR'S NAME:
Nedra Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Amy Goldenberg
TELEPHONE:
(951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE:
10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/25/2023
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
10/25/2023 02:33 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
CCLD Regional Office
,
1650 SPRUCE ST STE 200 MS29-27
,
CA
92507
FACILITY NAME:
GRACIOUS CARE INC #2
FACILITY NUMBER:
331880716
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of records and LPA observation the licensee did not comply with the section cited above as volunteers E1 and E2 are working without supervision which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/25/2023
Plan of Correction
1
2
3
4
Licensee to ensure that no volunteer is left unsupervised in the presence of residents at any time. LIC 500 to be provided to indicate appropriate staffing types for around the clock awake supervision.
Type A
Section Cited
HSC
1569.69(a)(3)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (3) An employee shall be required to complete the training requirements for hands-on shadowing training described in this subdivision prior to assisting any resident in the self-administration of medications. The training and instruction described in this subdivision shall be completed, in their entirety, within the first two weeks of employment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of employee records, the licensee did not comply with the section cited above in three (3) out of (3) records reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/01/2023
Plan of Correction
1
2
3
4
Licensee to provide training in the area cited by POC due date and maintain training records at all times at the facility.
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 Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Amy Goldenberg
TELEPHONE:
(951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE:
10/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/25/2023
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
10/25/2023 02:33 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
CCLD Regional Office
,
1650 SPRUCE ST STE 200 MS29-27
,
CA
92507
FACILITY NAME:
GRACIOUS CARE INC #2
FACILITY NUMBER:
331880716
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of employee training records, LPA observed no traiing records are maintained. The licensee did not comply with the section cited above in (3) out of (3) records reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/01/2023
Plan of Correction
1
2
3
4
Licensee to provide the required training to all employees and maintain training records at all times at the facility by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on designee interview the licensee did not comply with the section cited above. The facility is not maintaing records for disaster drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/01/2023
Plan of Correction
1
2
3
4
Licensee to develope a disaster log by POC due date and maintain documentation of disaster drills quarterly.
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 Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Amy Goldenberg
TELEPHONE:
(951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE:
10/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/25/2023
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
10/25/2023 02:33 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
CCLD Regional Office
,
1650 SPRUCE ST STE 200 MS29-27
,
CA
92507
FACILITY NAME:
GRACIOUS CARE INC #2
FACILITY NUMBER:
331880716
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(3)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on lack of training records present for review the licensee did not comply with the section cited above in (3) out of (3) employee records reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/01/2023
Plan of Correction
1
2
3
4
Licensee to conduct training and maintain training records at the facility by POC due date.
Type B
Section Cited
CCR
87705(c)(5)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review R1 and R2 have not had Medical Assessment updates since 2021. The licensee did not comply with the section cited above in (2) of (5) records reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/01/2023
Plan of Correction
1
2
3
4
Licensee to work with family to schedule reassessment by POC due date and provide dates of scheduled visits to CCL by POC due date.
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 Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Amy Goldenberg
TELEPHONE:
(951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE:
10/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/25/2023
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
10/25/2023 02:33 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
CCLD Regional Office
,
1650 SPRUCE ST STE 200 MS29-27
,
CA
92507
FACILITY NAME:
GRACIOUS CARE INC #2
FACILITY NUMBER:
331880716
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation of the last marked service tag of 01/01/2019 the licensee did not comply with the section cited above in they have not serviced or replaced their fire extinguisher annually which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/26/2023
Plan of Correction
1
2
3
4
Licensee to service or replace their fireextinguisher mounted in the dining room by POC due date and verification to be submitted to CCL within 24 hours.
Type A
Section Cited
CCR
87202(a)(2)
All facilities shall maintain a fire clearance approved by the city, county or city and county fire department...
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of the record for R4 indicating bedridded status of page 5 of 6 the licensee did not comply with the section cited above as evidenced by lack of bedridden fireclearance approval, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/26/2023
Plan of Correction
1
2
3
4
Licensee to notify local fire authority of R4's bedridden status and submit LIC 200 to seek approval for bedridden status by POC due date.
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 Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Amy Goldenberg
TELEPHONE:
(951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE:
10/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/25/2023
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
10/25/2023 02:33 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
CCLD Regional Office
,
1650 SPRUCE ST STE 200 MS29-27
,
CA
92507
FACILITY NAME:
GRACIOUS CARE INC #2
FACILITY NUMBER:
331880716
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(b)(2)(B)
The following persons are exempt from requirements applicable requirements...A volunteer to whome all of the following apply...The volunteer is not left alone with clients in care.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation of volunteers left alone to provide client care the licensee did not comply with the section cited above in (2) out of (2) staff scheduled at this facility. LPA arrived and E1 was alone caring for 5 residents. THey are cleared as volunteer only which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/26/2023
Plan of Correction
1
2
3
4
Licensee to immediately assign employee status clearance employees to care for residents. LIC 500 to be provided to CCL by POC due date.
Type A
Section Cited
CCR
87405(a)
All facilities shall have a qualified and currently certified administrator...The administrator shall have sufficient freedom from other responsibilities and shall be on the premesis a sufficient number of hours to permit adequate attention to management and administration of the facility as specified in this section.
This requirement is not met as evidenced by: Multiple serious deficiencies issued on this date are sympromatic that oversight of the facility is insufficiently being met by the licensee. The administrator reports overseeing (5) facilities as well as covering as caregiving at multiple locations.
Deficient Practice Statement
1
2
3
4
Based on the deficiencies regarding fire clearance, volunteers being left alone, fire safety, lack of updated records for residents and staff and missing training records it is evident the administrator is not available to provide the oversight needed. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/01/2023
Plan of Correction
1
2
3
4
Licensee to provide plan for administrator schedule to assure their time is sufficient and free from other obligations for 20 hours per week to oversee this facility by POC due date.
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 Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Amy Goldenberg
TELEPHONE:
(951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE:
10/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/25/2023
LIC809
(FAS) - (06/04)
Page:
7
of
8
Document Has Been Signed on
10/25/2023 02:33 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
CCLD Regional Office
,
1650 SPRUCE ST STE 200 MS29-27
,
CA
92507
FACILITY NAME:
GRACIOUS CARE INC #2
FACILITY NUMBER:
331880716
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel - Operations
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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 Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Amy Goldenberg
TELEPHONE:
(951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE:
10/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/25/2023
LIC809
(FAS) - (06/04)
Page:
8
of
8