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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880740
Report Date: 03/11/2024
Date Signed: 03/11/2024 03:10:27 PM


Document Has Been Signed on 03/11/2024 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:GRACIOUS CARE HOMEFACILITY NUMBER:
331880740
ADMINISTRATOR:BRANDON MARQUEZ GUTIERREZFACILITY TYPE:
740
ADDRESS:12515 HUDSON RIVER DRIVETELEPHONE:
(951) 444-6651
CITY:EASTVALESTATE: CAZIP CODE:
91752
CAPACITY:6CENSUS: 2DATE:
03/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:Vicente Picache, caregiverTIME COMPLETED:
03:13 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to deliver amended finding on complaint control number: 56-AS-20220621092755. LPA met with facility staff Vicente Picache and was informed of the reason for the visit.

Findings for the allegations remain as UNSUBSTANTIATED. The report was discussed with Mr. Picache and copies of this report and amended findings (LIC9099) were provided to Mr. Picache at the conclusion of today’s visit.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna FannellTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
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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