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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880740
Report Date: 12/08/2021
Date Signed: 12/08/2021 12:38:27 PM

Unfounded


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
12/01/2021 and conducted by Evaluator Amy Goldenberg
COMPLAINT CONTROL NUMBER: 18-AS-20211201102109
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:
12/08/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ariceli RIvas, House ManagerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility failed to issue a refund
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Goldenberg contacted the facility to conduct a 10 day complaint investigation visit. LPA identified herself to staff Ariceli Rivas and discussed the elements of the allegations with Sandy Zhao, Administrator via telephone.

During the course of this investigation LPA interviewed (1) one witness, the facility administrator to review refund policy, and one facility staff. LPA obtained copies of R1's admission agreement, R1's property release form and LPA requested but never received the staffing schedule for December.

In regard to the allegation that the facility failed to issue a refund LPA learned the following: R1 passed away on 09/15/2021. R1 left behind glasses, bible book, rosary, and a radio according to R1's personal property and valuables. Record review shows R1's representative signed these items out of the facility on 09/28/2021.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 18-AS-20211201102109
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 HOME
FACILITY NUMBER: 331880740
VISIT DATE: 12/08/2021
NARRATIVE
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R1's admission agreement signed 09/01/2019 discloses a refund condition and it reads in the second paragraph in the Refund Conditions policy, " Fees paid in advance will be refunded within 15 days of the removal of a deceased residents belongings." The Refund conditions do not indicate that daily charges will accrue for the days the items are left at the facility, as in this case are glasses, bible book, rosary, and a radio. R1's responsible party was provided a refund for the remaining days of the month of September 2021 that fell after the 28th. This refund falls in line with the admission agreement and technically does not violate any portion of Title 22, Division 6 of the California Code of Regulations.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/01/2021 and conducted by Evaluator Amy Goldenberg
COMPLAINT CONTROL NUMBER: 18-AS-20211201102109

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:
12/08/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ariceli RIvas, House ManagerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Insufficient staffing
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Amy Goldenberg contacted the facility to conduct a 10 day complaint investigation visit. LPA identified herself to staff Ariceli Rivas and discussed the elements of the allegations with Sandy Zhao, Administrator via telephone.

During the course of this investigation LPA interviewed (1) one witness and the facility administrator to review refund policy, and one facility staff. LPA obtained copies of R1's admission agreement, R1's property release form and LPA requested the staffing schedule for December 2021.

In regard to the allegation of Insufficient staffing review of the staffing schedule do not indicate that staffing is insufficient. Two staff are scheduled to be present. However, on this date LPA observed one (1) staff and three (3) residents present. All three residents required substantial care. It does not appear that one staff is sufficient to care for residents and maintain all other needs of the house such as laundry, cooking and assisting visitors.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20211201102109
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 HOME
FACILITY NUMBER: 331880740
VISIT DATE: 12/08/2021
NARRATIVE
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LPA was in the home from 1030-1200 and only one staff was present and they were caring for residents, was attempting to prepare food for lunch, and was assisting LPA with the visit. A second staff arrived around 1200. Staffing schedule provided to LPA by Licensee Sandy Zao indicates that there would be one caregiver/housekeeper and one House Manager will be present Monday through Friday 0700 through 1900. LPA observed that this is not always the case although it has been determined through the scheduling that two (2) staff are to be present.

Based on the aforementioned, 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 BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20211201102109
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 HOME
FACILITY NUMBER: 331880740
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2021
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
The facility has failed to meet this requirement as evidenced by
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Facility administrator to ensure that staffing needs are being fulfilled as indicated on the LIC500 provided to LPA.
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LPA observation of one staff present during LPA visit. This poses a risk to the health and safety of residnets in care.
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A copy of the current LIC500 to be present at all times at the facility, easily accessible to CCL staff.
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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: 12/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5