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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880716
Report Date: 02/29/2024
Date Signed: 02/29/2024 02:24:57 PM


Document Has Been Signed on 02/29/2024 02:24 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: 3DATE:
02/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kevin Galvan Bastidas TIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to the facility for a complaint. During the complaint visit, LPA Rico completed a case management visit to cite for three (3) deficiencies found during facility tour.

During facility tour, LPA observed the cleaning solutions in the laundry room without a lock. LPA requested for S1 to lock the cleaning solutions. During interviews with staff, S1 admitted they work 24 hours for 5 days Monday -Friday and are the only staff working at the facility. S1 stated that S2 will be working 24hours for 2 days Saturday – Sunday and are the only staff working at the facility. S1 also admitted the facility staff are in vacation. Furthermore, during an interview with the Administrator they admitted they not present during working hours because they are in Northern California.In addition, the Administrator also admitted the facility does not have a designated substitute who has the adequate qualifications to adequate to be responsible and accountable for the facility and is on premises 24 hours per day.

During today’s visit, four (4) Type A deficiencies to the facility were cited per Title 22, Division 6, of the California Code of Regulations.



An exit interview was conducted where this report, LIC809, LIC809D, Appeal Rights were discussed and provided to staff member Kevin Galvan Bastidas
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
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 3


Document Has Been Signed on 02/29/2024 02:24 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: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2024
Section Cited
CCR
87309(a)

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87309(a) Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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Licensee has agreed to send proof they have read and understood the regulation and will send proof they have trained all staff on the regulation cited above.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by not having cleaning solutions locked which poses an immediate Health, Safety or personal rights risk to persons in care.
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POC due date 03/01/2024
Type A
03/01/2024
Section Cited
CCR87413(a)(1)

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87413(a)(1) Personnel - Operations
(a) In each facility:
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.This requirement is not met as evidenced by:
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The licensee has agreed to provide an updated LIC 500 and provide the following documents of which staff members provide coverage while other staff are on vacation.
Licensee will submit Signed Statement of Understanding on the cited regulation to LPA Rico by POC due date.
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Based on observation, interview and record review the licensee did not comply with the section cited above evidenced by not providing staff coverage when regular staff are on vacation
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POC due date 03/01/2024
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) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/29/2024 02:24 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: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2024
Section Cited
HSC
1569.618(b)

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1569.618(b)Administration and management of residential care facilities; substituted qualifications; employee scheduling.(b).one ..manager..designated substitute qualifications.. responsible designated substitute shall meet..This requirement is not met as evidenced by:
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Licensee has agreed to have a designated susbstitue when the Administrator is not present. Licensee will send proof to LPA.
Licensee will submit Signed Statement of Understanding on the cited regulation to LPA Rico by POC due date.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by Licensee admitting not having a designated substitute which poses an immediate Health, Safety or personal rights risk to persons in care.
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POC due date 3/1/2024
Type A
03/01/2024
Section Cited
HSC1569.618(a)

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1569.618(a)Administration and management of residential care facilities; substituted qualifications; employee scheduling.(a)... operation of the facility when the administrator is temporarily absent from the facility.
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The licensee has agreed to send proof of when the Administrator will be return to the facility and copy of the schedule.
Licensee will submit Signed Statement of Understanding on the cited regulation to LPA Rico by POC due date.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by Administractor admitting they not present during working hours which poses an immediate Health, Safety or personal rights risk to persons in care.
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POC due date 3/1/2024
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) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3