331880716-2-29-2024-18-AS-EMAN-D84UPD-20240813154523

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880716
Report Date: 02/29/2024
Date Signed: 02/29/2024 02:12:33 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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 Mary Rico

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: 3	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Kevin Galvan Bastidas		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff does not properly report incidents involving residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegation listed above. LPA met with staff member Kevin Galvan Bastidas and explained the purpose of the visit. The investigation consisted of staff interviews, document reviews, and a facility tour.

For the allegation, Staff does not properly report incidents involving residents.

During interviews with staff, S1 and Administrator informed LPA that R1 had passed away at facility on 2/8/2024. Administrator admitted they did not submit the Death Report to Community Care Licensing. In addition, during resident event log it was documented that R1 had passed away on 2/8/2024. Furthermore, on resident event log review LPA discovered that R2 had a fall on 11/14/2023 and was also not reported to Community Care Licensing. In addition, Administrator admitted that R3 passed away at her facility and did not submit the Death Report.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (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.

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACIOUS CARE INC #2	FACILITY NUMBER: 331880716
	VISIT DATE: 02/29/2024

NARRATIVE

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Based on the evidence gathered during today’s investigation, the one (1) allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met.

During today’s visit, one (1) Type A deficiency were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) and (LIC9099D) was discussed and provided staff member Kevin Galvan Bastidas along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (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

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
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 87211(a)(1)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated to train all staff on CCR 87211(a)(1) and submit proof of Staff Training Log to LPA Rico by POC due date. Licensee will submit Signed Statement of Understanding on CCR 87211(a)(1) to LPA Rico by POC due date.
	8 9 10 11 12 13 14	Based on interview and records review, the Licensee did not comply with the section cited above by not submitting Special Incident Report (SIR) to CCL for R2 fall and R1 and R3 Death Report. This pose potential health, safety and personal rights risk to resident in care.	8 9 10 11 12 13 14	POC due date 3/1/2024
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	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: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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