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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880740
Report Date: 07/18/2023
Date Signed: 07/18/2023 01:47:50 PM

Unsubstantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/17/2021 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210817110059
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: 4DATE:
07/18/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Nidya Reynoso, CaregiverTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility is not following COVID-19 guidelines.
INVESTIGATION FINDINGS:
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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above. It is alleged that the facility is not following COVID-19 guidelines. Investigation included review of the facility emergency disaster plan and COVID-19 mitigation plan received 07/19/2021. LPA observed on the initial visit conducted on 08/19/2021 the following: Staff took LPA temperature, provided hand sanitizer, and had a sign in procedure. LPA was granted entry. Facility staff were all wearing masks. The facility has all the elements of their COVID-19 Mitigation Plan in place. Interview with staff during the time of the pandemic, revealed that visitations were not limited. However, the facility requested if family can call and let them know when they are going to arrive and as recommended if they had traveled or were not vaccinated to obtain a negative covid test. All visitation took place outside and wearing masks according to staff interviewed, and all staff are vaccinated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
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 2
Control Number 18-AS-20210817110059
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
, CA 92507
FACILITY NAME: GRACIOUS CARE HOME
FACILITY NUMBER: 331880740
VISIT DATE: 07/18/2023
NARRATIVE
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Based on the available information we have found the complaint allegation unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2