331881318-7-24-2023-18-AS-JROO-CU2S24-20230724132856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881318
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:29:01 PM

Document Has Been Signed on 07/24/2023 01:29 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
RIVERSIDE AC/SC, 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: 5	DATE:	07/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator Kanisha Arzu		TIME COMPLETED:	01:45 PM

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On 7/24/2023, at 11:45 a.m., Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Administrator Kanisha Arzu who was informed of the purpose of visit. The facility is made up of four (4) resident bedrooms and two (2) bathrooms. The facility is approved for six (6) non-ambulatory residents of which one (1) may be bedridden. The facility also has a hospice waiver for six (6) residents. During the visit, there was five (5) residents and two (2) staff present.

LPA conducted a tour of the facility’s interior and exterior and observed the following:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. LPA observed the facility met the requirement for a 2-day supply of perishable food and 7-day of non-perishable food items. Cleaning solutions and knives/sharp instruments are secured in a locked kitchen cabinet. Fire extinguisher is charged and mounted on kitchen wall.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. Facility has six recliner chairs available for the residents. LPA observed residents in their rooms and in common areas.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Carbon monoxide & smoke detectors were tested and functioning properly.

Continued on LIC809-C..

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ABUNDANT GRACE SENIOR LIVING	FACILITY NUMBER: 331881318
	VISIT DATE: 07/24/2023

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a locked kitchen cabinet. LPA reviewed physical medications for two residents as well as the Medication Destruction Record and no discrepancies discovered.

Bedrooms: Resident bedrooms were clean, and each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms were clean, and had a working toilet, wash basin, and grab bar in the shower. Bathroom sink hot water temperatures measured at 124- and 132-degrees Fahrenheit. Facility has warning signs to caution residents of hot water temperatures. The facility has clean towels, blankets, and linen, available in different colors for residents in care.

Laundry/Garage: LPA observed laundry room and garage to be clean. Washing machine and dryer are in good repair. Emergency food supplies, water and incontinent supplies are stored in the garage.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Staff training is up to date.

Yard/Outside Area: Covered patio seating is available for the residents. A brick wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

LPA did not observe any deficiencies. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Arzu.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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