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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880740
Report Date: 10/16/2024
Date Signed: 10/16/2024 02:35:21 PM


Document Has Been Signed on 10/16/2024 02:35 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, 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:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver- Karim Ibarra MoralesTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mary Rico and Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with caregiver Karim Morales and was granted entry to the facility. The facility is a (5) bedroom, (3), bathroom home and, with a kitchen/dining area, living room and attach garage. Licensed capacity is (6) current census (2). LPAs were accompanied by caregiver Karim Morales to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. The facility is equipped with operating carbon monoxide alarms and fire alarms. Posters such as personal rights, the CCL complaint poster, in the common area.Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Deficiencies that were found during facility tour: LPAs inspected residents’ bedrooms; R1 and R2 had mattresses, nightstands, storage space, but did not have chairs. During facility tour, LPAs observed two electric wires hanging off of the wall by residents’ bedrooms, this is fire hazard for residents in care. R1 and R2 did not have non-skid mats inside their bathroom tub. LPAs tested residents’ water; the temperature tested at 126 F. No cautions warning signs posted. In addition, during facility tour, LPAs observed the facility kitchen hallway, living area, resident’s hallways and (2) resident’s bedrooms did not have light installed nor lamps for appropriate lighting. LPAs inspected kitchen cabinets, (8) kitchen cabinets were dirty, with food crumbs and dirt. Furthermore, LPAs observed the window located by the dining area did not have a window screen install. LPAs and S1 tested facility phone, the phone was out of service. During facility tour, R1 and R2 bathroom was not free from incontinence odor. Next, LPAs tested exit monitor device for residents with dementia. The devices were turned off. The facility currently has (1) dementia residents, facility must always remain devices on.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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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Document Has Been Signed on 10/16/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview , the licensee did not comply with the section cited above by not having a designated substitiute present which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee stated they will send a copy of their designated substitutes along with their work schedule.
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above by having (8) kitchen cabins dirty which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee stated they will clean their kitchen cabins, and will send proof to LPA Rico.
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview , the licensee did not comply with the section cited above by not having lights working in the kitchen hallway, living room, and resident's hallway which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee stated they will repair facility lights, and will send proof to LPA Rico.
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation , the licensee did not comply with the section cited above . The water tested at 126 F and did not have warning signs which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee stated they will post warning signs in resident's bathrooms, and will send proof to LPA Rico.
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview record review, the licensee did not comply with the section cited above. S1 stated they work all day, based on LIC500 staff schedule were not present which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee stated they will send an update LIC500 along with staff schedule.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, S1 did not have a CPR card which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee stated they will enroll S1 to a CPR class and will send proof to LPA. Licensee also stated they will send a copy of all staff CPR.
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record S1 did not have a request for their criminal record clearance to be transfer, 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: 10/17/2024
Plan of Correction
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Licensee stated they will transfer S1 criminal record clearance and will send proof to LPA Rico.
Type A
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having R1 PRN medication record of the time, date and resident response which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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2
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Licensee stated they will train their staff on the regulation cited above and will send proof to LPA Rico.
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review , the licensee did not comply with the section cited above by not having R1 medication listed on MAR file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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2
3
4
Licensee stated they will have R1 medication listed on their file, and will send proof to LPA Rico.
Type A
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based onrecord review , the licensee did not comply with the section cited above by R2 not having their annual medical assessment, last annual was dated of the year 2021, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
1
2
3
4
Licensee stated they will send proof to LPA they have schedule a medical assessment for R2.
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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
SAN BERNARDINO, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above the facility did not have the alert devices on which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
1
2
3
4
Licensee stated they will train their staff on the regulation cited above and will send a copy to LPA Rico. Before leaving the facility, LPA Rico requested the devices to be turned on.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review , the licensee did not comply with the section cited above by not having the plan of operation in the faciity file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
1
2
3
4
Licensee stated they will read the regulation cited above and will also send proof the plan of operation is located inside the facility file.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not having a window screen by the dining area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
1
2
3
4
Licensee stated they install a screen on the window and will send proof to LPA Rico.
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above by not having non-skid mats for R1 and R1 bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
1
2
3
4
Licensee stated they will put non-skid mats for R1 and R2 bathroom. Licensee informed LPA they will send proof to LPA Rico.
Type B
Section Cited
CCR
87307(a)(3)(B)
Personal Accommodations and Services
(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation , the licensee did not comply with the section cited above by not having a chair for R1 and R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
1
2
3
4
Licensee stated they will provide a chair for R1 and R2 and will send proof to LPA.
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 9 of 14


Document Has Been Signed on 10/16/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87311
Telephones
All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, S1 and LPA Rico tested the facility phone, the line was out of services which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
1
2
3
4
Licensee stated they having a working facility phone, and will send proof to LPA Rico.
Type B
Section Cited
HSC
1569.618(c)(4)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having two electric wires hanging off facility wall by residents bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
1
2
3
4
Licensee stated they will have electric wires repaired and will send proof to LPA Rico.
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 10 of 14


Document Has Been Signed on 10/16/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above the facility did not have activities for residents,and during facility inspection no activities were provided which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee stated they will train their staff on the regulation cited above and will send a copy of resident activites.
Type B
Section Cited
CCR
87465(a)(8)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review , the licensee did not comply with the section cited above by not having a complete kit approved by American Red Cross which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee stated they will send proof to LPA the first aid kit contains all the following items.
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 11 of 14


Document Has Been Signed on 10/16/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)(A)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above by a current edition first aid manual approved by the American Red Cross which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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2
3
4
Licensee stated they will send proof the facility has purchase the current edition first aid manual approved by the American Red Cross
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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2
3
4
Licensee stated they create the disater plan LIC 610 and send a copy to LPA Rico
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 12 of 14


Document Has Been Signed on 10/16/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not having R1 and R2 bathroom free from incontient odor which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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2
3
4
Licensee stated they will train their staff on the regulation listed above, clean R1 and R2 bathroom, and will send proof to LPA Rico.
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above which poses/posed by not having R1 hospice care plan potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
1
2
3
4
Licensee stated they will send a copy to LPA Rico and will send proof R1 hospice careplan is maintained at the facility.
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 13 of 14


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GRACIOUS CARE HOME
FACILITY NUMBER: 331880740
VISIT DATE: 10/16/2024
NARRATIVE
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In addition, no activities were provided during inspection and the facility did not have activities listed for the residents. Lastly, LPA observed the facility did not have their First Aid Kit completed and did not have the American Red Cross Manual current edition.

Delicacies that were found during record review: LPAs observed the facility did not have their Plan of Operation in their facility file and no Disaster Plan 610. In addition, R1 did not have their hospice care plan in file, and R2 did not have their annual medical assessment which is required for dementia resident. Furthermore, R1 did not have (1) of their medication listed on their MAR and did not have their PRN documented with the time, date, and resident response. Lastly, during criminal record clearance check, LPAs observed S1 is not associated to the facility. The licensee was advised to submit transfer request.

Deficiencies that were found during care & supervision: The facility does not have sufficient staff coverage, based on the LIC500 the staff members that were scheduled were not present. During staff interview, S1 stated they will be working over 24 hours. During facility annual inspection, the facility did not have a designated staff present, house manager or Administrator present. Moving forward the licensee shall ensure the facility has designated staff present or Administrator present for 24 hours as stated in Tittle 22 Regulations.

Based on observations today, a civil penalty in the amount of $500.00 dollars will be issued for not transferring S1 criminal record clearance. The facility will be issued (11) Type A deficiencies and (12) Type B deficiencies per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed to Licensee Sandy Zhao on the phone and was provided to caregiver Karim Ibarra Morales along with a copy of LIC809D, LIC421BG, and the appeal rights.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 14 of 14