331880716-2-7-2022-18-AS-EMAN-D84UPF-20240813154525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880716
Report Date: 02/07/2022
Date Signed: 02/07/2022 01:53:38 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2021 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210520160259

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: 6	DATE:	02/07/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Caregiver Arceli Rivas		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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There is not enough staff to meet the residents needs

INVESTIGATION FINDINGS:

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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to further investigate the above-mentioned complaint allegation.

Investigation consisted of review of resident census, review of six (6) resident records, review of six (6) resident admission agreements, and interview with one facility staff (S1).

Investigation revealed the following: Six (6) of six (6) admission agreements reviewed state on Page 3, Basic services, at first bullet point, "Twenty-four (24) hour care and supervision, seven days per week, all year long". Interview and observation revealed the following: The facility currently has six (6) residents in care and one caregiver (S1). Interview of S1 revealed that they have been on duty alone since 1330 on 02/06/2022.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20210520160259

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACIOUS CARE INC #2	FACILITY NUMBER: 331880716
	VISIT DATE: 02/07/2022

NARRATIVE

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S1 is doing all the resident care, cooking and screening of visitors and is left to also assist with this visit with LPA Goldenberg drawing them away from resident care. Review of resident records revealed the following: Four (4) of six (6) residents require moderate care in all activities of daily living. Three (3) of six (6) residents have a diagnosis of Dementia and require supervision. One (1) of six (6) residents requires assistance with ambulation.

S1 admits to being tired and without assistance for the last 24 hours, but also states has been on duty even longer providing care for residents around the clock. It is clear that there is not enough staff to provide a safe environment in which staff are able to meet the residents needs according to their assistance level and admission agreement.

We have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20210520160259

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 02/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/07/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Based on observation, record review and observation the facility is not meeting this requirement	1 2 3 4 5 6 7	Licensee will immediately provide additional staffing in order to regain a safe environment for meeting residents needs. If staff is not available the administrator or Licensee will come to the facility
	8 9 10 11 12 13 14	as evidenced by one caregiver working alone for the past 24 hours without help and providing care for residents with dementia which requiring moderate physical assistance.	8 9 10 11 12 13 14	to provide assistance by close of business (1700) 02/07/22. Proof of correction to be emailed to LPA Goldenberg by close of business. Failure to correct will result in civil penalty assessments.
	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 Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

LIC9099 (FAS) - (06/04)

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