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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881283
Report Date: 06/16/2023
Date Signed: 06/16/2023 02:01:27 PM


Document Has Been Signed on 06/16/2023 02:01 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:GRACE HOME TAVELFACILITY NUMBER:
331881283
ADMINISTRATOR:HANH, JENNIFERFACILITY TYPE:
740
ADDRESS:35224 TAVEL STTELEPHONE:
(714) 814-4287
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:6CENSUS: 4DATE:
06/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Jennifer Hahn, Administrator/LicenseeTIME COMPLETED:
02:00 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Grace Home Tavel Residential Facility for the Elderly unannounced to conduct an Annual Inspection. LPA rang doorbell and was greeted by staff at the door. LPA introduced self and stated purpose of the visit. LPA was granted entry and asked to sign in the Visitors Log. Staff notified Administrator, Jennifer Hanh of LPA visit and met with LPA at the door. Administrator then accompanied LPA during inspection.

LPA conducted a tour of the facility, both inside and outside, and observed the following:

Facility: LPA was informed the current census is four (4) at time of visit. The facility is licensed for six (6) residents. Two (2) ambulatory residents and four (4) bedridden residents. There is a Hospice Waiver in place. The facility is approved for 4 Hospice residents. LPA observed that the facility is operating in the capacity and conditions approved by Community Care Licensing (CCL).
Physical Plant: LPA observed the facility's temperatures to be comfortable. Water temperature was measured at 118.0 degrees Fahrenheit. Showers and toilets are functional. Each bathroom equipped with grab bars and sufficient paper and hand hygiene supplies. Linens and hygiene items observed are sufficient for the number of residents in care. Each resident room is equipped with regulated furniture, lamps that provide appropriate lighting for residents comfort and safety. The facility is equipped with operational smoke alarms and carbon monoxide detectors. Fully charged fire extinguishers - last inspected June 2022. LPA reviewed the facility's Emergency Disaster Plan and Fire Drills and observed that the facility conducts quarterly Fire/Earthquake Drills - last drill took place in February of 2023.
Food Service: Nonperishable and perishable food is sufficient for number of residents in care. Food is being prepared and stored properly. Facility has a variety of food available for residents according to the posted food menu. LPA observed staff preparing lunch for residents.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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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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: GRACE HOME TAVEL
FACILITY NUMBER: 331881283
VISIT DATE: 06/16/2023
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Care & Supervision: Facility has sufficient care staff as regulated. Toxic and sharp items are kept inaccessible to residents in care and stored and locked in a cabinet adjacent to the kitchen.
Record Review and Resident/Staff Files: LPA reviewed records for two (2) residents currently residing at the facility. Resident records are complete with updated Physician Reports and Needs and Services Plans. LPA also reviewed staff files and confirmed that staff records reflect current CPR/First Aid Certification and Criminal Record Clearance. The Administrator's Administrator Certificate is in good standing.
Administration: Disaster/Evacuation Plan, Long Term Care Ombudsman Poster, Administrator Certificate, Resident Personal Rights, and facility license are posted in a common area in the Facility. Emergency Disaster Plan is current.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and locked in a file cabinet near the staff office. LPA reviewed all the residents' medications and compared it to the facility's Medication Administration Report (MARs) and Centrally Stored Medication Log. No medication errors observed.

Based on today's inspection, no deficiencies were observed. Exit interview conducted and copy of this report was provided to Administrator/Licensee Jennifer Hanh
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC809 (FAS) - (06/04)
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