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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880809
Report Date: 11/17/2021
Date Signed: 11/17/2021 01:41:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ABOUNDING GRACE CARE HOME, INC.FACILITY NUMBER:
331880809
ADMINISTRATOR:DELA CRUZ, CHERYLFACILITY TYPE:
740
ADDRESS:26152 WINDEMERE WAYTELEPHONE:
(951) 961-1303
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 4DATE:
11/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Aurora Cuasay - StaffTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Crystal Colvin and Venus Mixon arrived at the facility unannounced for the purpose of conducting a initial inspection regarding complaint (#18-AS-20211110100838). LPA Colvin met with staff Aurora Cuasay and advised them of the purpose of the visit. Licensee/Administrator Cheryl De La Cruz was not present during today's inspection. During today's complaint investigation, the following additional violations were observed:
  • Resident Files - LPAs observed that there was no/incomplete file for at least one resident (R1) during today's visit, which was missing vital information. Deficiency cited.
  • Staff Files - LPAs observed that there were no staff files for two staff present at the facility during the inspection (S1 & S2). Deficiency cited.
  • Fingerprint Clearance - LPAs confirmed that two staff members present (S1 & S2) did not have current approved fingerprint clearance and therefore are not allowed to work in any facility licensed by Community Care Licensing (CCL). Deficiency cited. Additionally, civil penalties will be issued for each staff at $100 per day that each has been present at the facility. Aurora informed LPAs that S1 has been working at the facility since earlier this month, and S2 started today. $500 is being issued for S1 ($100 x 5 days) and $100 for S2 ($100 x 1 day), for a total of $600.
  • Medication Records - LPAs observed that there is no Centrally Stored Medication Log in the facility for R1's medications, which would state the date the prescriptions were filled, as well as other vital information. Deficiency cited.
  • Unlocked Medications - LPA Colvin observed unlocked medication in the refrigerator. Centrally stored medication must be locked and secured away from everyone except staff at all times. Deficiency cited.
  • PRN Medication Records - LPA Colvin observed that R1 has multiple PRN (as needed) medications for which the facility does not have a signed prescription order from the physician advising for what symptoms R1 needs the medication and when it should be administered. Deficiency cited.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ABOUNDING GRACE CARE HOME, INC.
FACILITY NUMBER: 331880809
VISIT DATE: 11/17/2021
NARRATIVE
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Due to the violations of Title 22 Regulations observed during today's inspection, the facility was cited multiple deficiencies and civil penalties in the amount of $600 were assessed.

Due to the multiple deficiencies cited during today's inspection, LPA Colvin is requesting for the Licensee to attend a virtual Informal Meeting on December 3, 2021 at 10am via Zoom. LPA Colvin is additionally requesting for staff Aurora Cuasay to attend, as it was stated that Aurora will be submitting an application for Change of Ownership to take over the facility. LPA Colvin to send an email with the invitation and link to the zoom meeting to both parties.

LPAs Colvin and Mixon conducted an exit interview with staff Aurora Cuasay and a copy of this report, LIC809D, LIC421BGs, and appeal rights were provided.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ABOUNDING GRACE CARE HOME, INC.
FACILITY NUMBER: 331880809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited

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Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by:
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Based on record review, the Licensee did not comply with the above regulation with at least one resident. LPAs observed the file for R1 to be missing most documents, including Physician's Report, Pre-Appraisal, and Admissions Agreeement. This is an immediate safety risk to R1.
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of all documents required to be in every resident's file. Self-Certification and Statement of Understanding to be submitted to LPA Colvin by Plan of Correction date of 11/18/21.
Type B
12/03/2021
Section Cited

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Personnel Records: (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement was not met as evidenced by:
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Based on record review, the Licensee did not comply with the above regulation with at least two staff (S1 & S2). LPAs observed that there were no staff files present for S1 or S2. This is a potential safety risk for all residents in care.
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Statement of Understanding of all documents required to be in every staff's file. Self-Certification and Statement of Understanding to be submitted to LPA Colvin by Plan of Correction date of 11/18/21.
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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ABOUNDING GRACE CARE HOME, INC.
FACILITY NUMBER: 331880809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited

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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: (1) Obtain a California clearance...as required by the Department... This requirement was not met by:
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Based on record review, the Licensee did not comply with the above regulation with two staff members (S1 & S2). LPA Colvin confirmed that neither S1 nor S2 have approved fingerprint clearance to work at a licensed facility. This is an immediate health and safety risk to all residents in care.
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are out. Licensee to ensure adequate staff coverage at all times. Staff schedule to be submitted to LPA Colvin by Plan of Correction date of 11/18/21.
Type B
12/03/2021
Section Cited

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Incidental Medical and Dental Care: (h) The following requirements shall apply...: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained... and includes: (E) The prescription number... This requirement was not met by:
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Based on record review, the Licensee did not comply with the above requirement with at least one resident. LPAs observed that R1 has multiple PRN medications but did not observe a record of the medication which lists the prescription number. This is a potential health risk to R1.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ABOUNDING GRACE CARE HOME, INC.
FACILITY NUMBER: 331880809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited

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Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement was not met by:
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Based on observations, the Licensee did not comply with the above regulation with one medication (insulin). LPA Colvin observed unlocked/unsecured insulin in the facility's kitchen fridge, which was easily accessible. This is an immediate health/safety risk to all residents in care.
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Type B
12/03/2021
Section Cited

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Incidental Medical and Dental Care: (e) For every prescription and nonprescription PRN medication...there shall be a...written order from a physician...maintained in the residents file... shall contain... (1) The specific symptoms which indicate the need for the use of the medication. This requirement was not met by:
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Based on record review, the Licensee did not comply with the above requirement with at least one resident. LPAs observed that R1 has multiple PRN medications, but there was no written order which stated the symptoms for which the medications are for. This is a potential health risk to R1.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5