331881318-7-7-2022-18-AS-YDEO-CG4V5H-20220707160756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881318
Report Date: 06/23/2022
Date Signed: 07/07/2022 04:09:58 PM

Document Has Been Signed on 07/07/2022 04:09 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ABUNDANT GRACE SENIOR LIVING		FACILITY NUMBER:	331881318
ADMINISTRATOR:	ARZU, KANISHA		FACILITY TYPE:	740
ADDRESS:	43307 PUTTERS LANE		TELEPHONE:	(562) 551-1218
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	6	CENSUS: 0	DATE:	06/23/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kanisha Arzu, Administrator		TIME COMPLETED:	12:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:30 AM, LPA met with Licensee/Administrator Kanisha Arzu. An initial application for to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 1/5/2022 for a total capacity of five (5) non-ambulatory and one (1) bedridden residents. Fire clearance was granted on 4/27/2022. LPA Delgado observed the following: Structure: Facility was a one-story house with four (4) resident bedrooms, two (2) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the back of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Each resident bedroom #2 (shared) , #3 (shared), #4 will accommodate any non-ambulatory resident, bedroom #1 will accommodate bedridden residents. 4 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: The (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:00 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 138 degrees Fahrenheit. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. There were no Knives/sharp instruments observed, Licensee advised they will be secured in a locked drawer located in the kitchen cabinet . There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

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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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: ABUNDANT GRACE SENIOR LIVING	FACILITY NUMBER: 331881318
	VISIT DATE: 06/23/2022

NARRATIVE

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(CONTINUED FROM LIC 809)
and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the home. Laundry detergents and cleaning supplies were observed in locked cabinet inside the laundry room away from residents.
Living/Family room:
There was a living room with 6 reclining chairs for all clients and a TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.
Yards/Outside:
Patio table, 6 chairs, a bench with shade were observed in the backyard. There was a gate on the North side and South side of the property with a self-latching from the exterior doors that needs to be repaired. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the Dining area, Laundry room and each resident's bedrooms. Obudsman poster was not observed and Let-Us-No poster observed.
General items:
One (1) fire extinguishers were charged and located in the kitchen. Seven (7) smoke alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked yellow cabinet in the Staff office. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply was observed however the required 72-hour emergency food supply was not discernible from the regular food supply. Component III was completed on this day as well.
(CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ABUNDANT GRACE SENIOR LIVING	FACILITY NUMBER: 331881318
	VISIT DATE: 06/23/2022

NARRATIVE

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(CONTINUED FROM LIC 809)

Pre-Licensing is incomplete and the following corrections to be resolved by 6/30/2022:

Add the camera locations on the Facility sketch
Add the camera use to the Facility plan of operations for residents/representatives to be aware of cameras in facility
obtain a separate 72-hour emergency food supply
obtain additional emergency water
obtain and post visiting policy
obtain 30-Days of PPE supplies
obtain night lights for main hallway
obtain night lights for kitchen/dining area
obtain Obudsman poster
obtain generator for emergency power
obtain additional keys for facility vehicle
replace locks on cabinet doors in laundry room
replace locking mechanism for South and North exterior gate doors
replace trash cans with lids
repair padding to the bottom of the exterior door in Bedroom #1
readjust water temperatures for kitchen sink, bathroom sinks and showers between the temperature of 105 degrees Fahrenheit and no greater than 120 degrees Fahrenheit and verified by a licensed Plumber.
remove black inactivated cameras from the the premises

An exit interview was conducted, and a copy of this report was given.

"Pre-Licensing deficiencies have been resolved. Pre-Licensing is now complete."

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

LIC809 (FAS) - (06/04)

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