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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880809
Report Date: 10/19/2022
Date Signed: 12/08/2022 11:13:13 AM


Document Has Been Signed on 12/08/2022 11:13 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/08/2022 10:57 AM

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

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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA arrived at approximately 2:20 PM, signed in and utilized hand sanitizer. The LPA met with Administrator, Aurora Cuasay, and informed her of the purpose of her visit. There are currently no cases of COVID-19 within the facility.

During today's visit, the LPA toured the home and made observations pertaining to the facility's infection control measures. The LPA observed sufficient hand hygiene supplies and sufficient cleaning and disinfecting provisions. The facility does not have a designated infection control lead person who is responsible for overall infection control. The facility has a Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report in place which is pending review from the Department. The LPA observed sufficient Personal Protective Equipment (PPE) and sufficient cleaning supplies.

On this visit it was found that Staff One (S1) and Staff Two (S2) do not have a California Fingerprint Clearance. Interviews revealed S1 and S2 work and/or reside in the facility. This poses a potential health, safety and personal rights risk to the residents in care. A citation and civil penalties will be issued.

Due to insufficient time, a return visit will be conducted to continue the inspection. An exit interview to review this report was conducted with Cuasay and a copy was provided.

NOTE: This report was amended on December 08, 2022.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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 10/19/2022 04:45 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
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: 10/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
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 or a criminal record exemption as required by the Department...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that two uncleared adults were found to be working and/or residing at the facility. LPA observed Staff One (S1) and Staff two (S2) to be at the facility. Per Staff, S1 and S2 do work and/or reside at the facility. The Guardian Employee Roster indicates neither S1 nor S2 have been cleared to be in the faciliy. This poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 10/19/2022
Plan of Correction
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S1 and S2 left the premises prior to the conclusion of the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
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