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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880740
Report Date: 11/08/2021
Date Signed: 11/29/2021 12:46:25 PM

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
RIVERSIDE, CA 92507
FACILITY NAME:GRACIOUS CARE HOMEFACILITY NUMBER:
331880740
ADMINISTRATOR:ZHAO, NAFACILITY TYPE:
740
ADDRESS:12515 HUDSON RIVER DRIVETELEPHONE:
(951) 444-6651
CITY:EASTVALESTATE: CAZIP CODE:
91752
CAPACITY:6CENSUS: 3DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Dolores Spuentes, Caregiver
Aricelli Rivas, Caregiver		TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Goldenberg made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA is informed that there are no COVID positive individuals in the home. The facility has an approved mitigation plan on file with this agency. There is screening of visitors upon entry into the facility.

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and has a limited supply of Personal Protective Equipment (PPE). LPA discussed the availability of additional PPE supplies to the facility at the time of this visit and advised the facility representatives to contact our office in the event additional supplies are necessary. The facility continues to monitor residents regularly for any changes in condition, and notify the residents physician and emergency personnel in the event the client presents any COVID-19 symptoms.

Based on observations made during today’s inspection, the facility has deficiencies in the area of care of a person with dementia. LPA observed the facility knife drawer does not have a lock and laundry soap and other chemicals were accessible through a door that did not lock. These are immediate health and safety risk to the persons in the home. LPA observed through review of records that R1 has a diagnosis of dementia and the physician's report has not been updated annually as required. Please see LIC809 D for deficiencies cited per Title 22, Division 6, of the California Code of Regulations.

LPA reviewed this report with and a copy was provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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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
RIVERSIDE, CA 92507

FACILITY NAME: GRACIOUS CARE HOME
FACILITY NUMBER: 331880740
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
8770(f)(1)
(f)The following shall be stored inaccessible to residents with dementia: (1) knives, matches, firearms, tools, and other items that could constitute a danger to residents.

This requirement is not met as evidenced by: knife drawer does not have a lock and/or was not locked at the time of inspection.
Deficient Practice Statement
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Based on LPA observation of knife drawer does not have a lock and/or was not locked at the time of inspection, the licensee did not comply with the section cited above and this poses an immediate health, safety risk to persons in care.
POC Due Date: 11/09/2021
Plan of Correction
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Please allocate a space to store knives which is inaccessible to residents in care by POC due date of 11/09/2021, which is 24 hours from the issue of this deficiency.
Type A
Section Cited
CCR
87705(f)(2)
(f) The following shall be stored inaccessible to residents with dementis: (2) Over-the-counter medications, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by: Laundry and other cleaning supplies stored in an unlocked laundry room accessible to residents and others.
Deficient Practice Statement
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Based on LPA observation of unlocked cleaning supplies, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2021
Plan of Correction
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Please allocate a space to store the items listed above in section (2) by POC due date of 11/09/2021, which is 24 hours from the issue of this deficiency.
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 BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
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