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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880716
Report Date: 03/07/2024
Date Signed: 03/07/2024 01:04:01 PM


Document Has Been Signed on 03/07/2024 01:04 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:
03/07/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Kevin Galvan Bastidas TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mary Rico and Bianca Wolcott conducted an unannounced visit to the facility to verify clearance of Plan of Correction from visit on 02/29/2024. LPA Rico and Wolcott met with caregiver Kevin Galvan Bastidas. During today's visit, Licensee Sandy Zhao was contacted and informed of the visit.

The following deficiencies were not cleared during the time of the visit:

The Licensee was cited on 02/29/2024 for 87309(a) Storage Space. During today's visit and based on record review and interview, LPA Rico observed that the licensee did not have staff training on site. The Plan of Correction was to train all staff on 87309(a) Storage Space. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for six (6) days.

The Licensee was cited on 02/29/2024 for 87413(a)(1) Personnel – Operations. During today's visit and based on record review and interview, LPA Rico observed that the licensee did not submit the updated LIC500 and signed statement of understanding on the cited regulation. The Plan of Correction was to update LIC 500 and send a copy to LPA Rico. In addition, the Licensee was to submit Signed Statement of Understanding on the cited regulation to LPA Rico. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for six (6) days.

The Licensee was cited on 02/29/2024 for 1569.618(b) Administration and management of residential care facilities; substituted qualifications; employee scheduling. During today’s visit and based on interview, LPA Rico observed that the licensee did not have a designated substitute present. The Plan of Correction was for the licensee to have a designated substitute when the Administrator is not present and send proof to LPA Rico. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for six (6) days.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
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 2


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
VISIT DATE: 03/07/2024
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The licensee was cited on 02/29/2024 for 1569.618(a) Administration and management of residential care facilities; substituted qualifications; employee scheduling. During today’s visit and based on an interview, LPA Rico observed that the licensee did not have an Administrator present during working hours. The Plan of Correction was for the licensee to send proof of when the Administrator will return to the facility and a copy of the schedule. Along with a signed statement of understanding on the cited regulation to LPA Rico. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for six (6) days.

The licensee was cited on 2/29/2024 for 87211(a)(1) Reporting Requirements. During today’s visit and based on an interview, LPA Rico observed that the licensee did not have staff training on site. The Plan of Correction was for the licensee to train all staff 87211(a)(1) Reporting Requirements and submit proof of Staff Training Log to LPA Rico, along with a signed statement of understanding on the cited regulation to LPA Rico. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for six (6) days.

An exit interview was conducted with caregiver Kevin Galvan Bastidas where this report, LIC809 along with Civil Penalty Assessment pages, and Appeal Rights were reviewed and provided.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
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