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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881318
Report Date: 07/24/2024
Date Signed: 07/24/2024 11:36:24 AM


Document Has Been Signed on 07/24/2024 11:36 AM - 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ABUNDANT GRACE SENIOR LIVINGFACILITY NUMBER:
331881318
ADMINISTRATOR:ARZU, KANISHAFACILITY TYPE:
740
ADDRESS:43307 PUTTERS LANETELEPHONE:
(562) 551-1218
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 6DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Kanisha Arzu, AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with Administrator, Kanisha Arzu. She was notified of the purpose for the visit.

PHYSICAL PLANT: Residents appear to be protected against immediate hazards. Outdoor and indoor passageways are kept free of obstruction. No pool or body of water was observed on the property. According to the Administrator, there are no weapons kept on the property. Disinfectants, cleaning solutions, and poisons were inaccessible to residents in care. A comfortable temperature was being maintained in the home. There was sufficient lighting in resident bedrooms to ensure the comfort and safety of residents. Hot water signs were observed to be posted in resident bathroom. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped residents is available. The smoke and carbon monoxide alarms were tested and found to be in operating condition. The interior and exterior areas of the home were observed to be exceptionally clean, safe and organized.

FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. Sufficient supplies for resident's dinning use was observed to be available.

RECORD REVIEW: Staff files had required training; including, but not limited to, First Aid/CPR, Reporting Requirements, and Emergency and Disaster Training. Hospice training has been completed for care staff. Hospice Care Plans are on file fore residents in care. Staff present had the required criminal record clearances. Admission Agreement, Medical Assessment (Physician's Report), Assessments, and Service Plans were observed on file for residents in care. Administrator Arzu has an active Administrator's
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ABUNDANT GRACE SENIOR LIVING
FACILITY NUMBER: 331881318
VISIT DATE: 07/24/2024
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certificate, which expires on 02/22/2025. The facility currently has 4 residents in care receiving hospice services; which is within their Hospice Waiver limit. According to Arzu, the Licensee (GRACE AND LOVE RESIDENTIAL CARE HOME LLC) is active with the California Secretary of State and Limited Liability Insurance is in place.

MEDICATION: Medication storage areas were inspected. Medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to residents in care.

No deficiencies have been cited at this time. This report was reviewed with Administrator Arzu and a copy was provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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