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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880740
Report Date: 12/12/2023
Date Signed: 03/11/2024 03:10:37 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
06/21/2022 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220621092755
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: 2DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Alba Reynoso, CaregiverTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Resident's were denied visitors while in care.
Resident's care needs are not being met while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent visit on this day to deliver an amended report to the above-mentioned complaint allegations. LPA Amy Goldenberg completed the visit on 12/12/2023. Findings for the allegations are still unsubstantiated.

During the course of the investigation, interviews were conducted, a review of resident records was completed and copy of pertinent documents obtained. It is alleged that Licensee Sandy Zhao and an unknown staff denied a family member visitation with R1. Investigation revealed the following information: Interview with the reporting party revealed that on 06/20/2022 a visitor attempted to visit R1 and the facility staff would not allow the visitor access into the home and law enforcement was called to gain access. There are no court orders preventing anyone visitation with R1.
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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20220621092755
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: 12/12/2023
NARRATIVE
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Interview with the house manager confirmed that R1's visitor called law enforcement to the home. The house manager and licensee both deny not granting the visitor to see R1, however, the visitor refused to follow COVID protocols in place at that time of Covid vaccination or rapid testing results and/or masking. The house manager and licensee claim that attempts were made to accommodate the visit. All parties report that the visitor was able to see R1 after a solution was reached.

It is alleged that R1's care needs are not being met. Investigation included review of R1's record, interview with witness and facility staff. LPA toured the facility and made observation of residents in care. LPA did not observe any signs that two (2) of two (2) residents are not being cared for. One witness interviewed reports that the care their family member has received has been good. Interviews and review of R1's available record does not reveal any information to conclude that a violation occurred.

Based on the aforementioned, we have found the complaint allegations unsubstantiated. Although the alleged violations may have occurred or are valid, there is not a preponderance of evidence to prove that a violation occurred.

This report was reviewed with and a copy was provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2