331881335-6-2-2022-18-AS-CNWE-CEZVJA-20220602162825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881335
Report Date: 06/02/2022
Date Signed: 06/02/2022 04:28:36 PM

Document Has Been Signed on 06/02/2022 04:28 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:	FOR HIS GRACE SENIOR CARE HOME		FACILITY NUMBER:	331881335
ADMINISTRATOR:	NAVARRA, TERESA		FACILITY TYPE:	740
ADDRESS:	12537 POINSETTA DR		TELEPHONE:	(951) 689-0182
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	6	CENSUS: 1	DATE:	06/02/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Melayna Lagasca, Licensee		TIME COMPLETED:	04:30 PM

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Licensing Program Analysts (LPA) Chinwe Nwogene conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation. LPA met with Applicant, Melayna Lagasca. An initial application to operate a Residential Care Facility for Elderly (RCFE) was received by the Central Applications Bureau (CAB) on 03/28/2022 for a total of (4) bedridden clients and 2 non-ambulatory clients. Fire Clearance was granted for four (4) bedridden clients and 2 non-ambulatory on 04/26/2022.

LPA observed the following:

Structure: Facility was a one story house with Five (5) client bedrooms, three (3) bathrooms, family room, dining area/ Living Room, and kitchen. There was an attached two car garage in the front of the house.

Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in hallway to control entire house.

Bedrooms: Each client bedroom will accommodate any ambulatory client. All client bedrooms were adequately furnished with bed, chair, closet, clothing storage, adequate lighting, and an operable smoke alarm/carbon monoxide detector.

Bathrooms: All three bathrooms have a working toilet, wash basin, and shower. LPA tested water temperatures in client bathrooms. LPA verified water temperatures were measured at 103 and 104 degrees Fahrenheit.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies were secured in a locked cabinet in the garage. Knives/sharp instruments will be stored in a locked box located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition

(CONTINUED ON LIC 812C)

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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: FOR HIS GRACE SENIOR CARE HOME	FACILITY NUMBER: 331881335
	VISIT DATE: 06/02/2022

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(CONTINUED FROM LIC 812)

and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry area with washer and dryer were located in the garage.

Living/Family room: There was a family room with safe and adequate seating for all clients as well as working TV.

Linens and Hygiene Supplies: An adequate supply of linens was stored in the resident’s draw, cabinet in the hall and Cabinet in the garage.

Yards/Outside: Fencing secured the entire backyard. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property.

Garage: Garage was being utilized with packed boxes.

Emergency Phone Numbers, and Exit Plan: Covid-19 Posters, Let-Us-No poster, emergency phone numbers, and facility sketch were posted by the hallway.

General items: One (1) fire extinguisher was mounted on the wall in between the kitchen and the family room. Smoke alarms/carbon monoxide detectors were tested and were in working order. Client records were stored in a locked file cabinet by the kitchen. LPA observed First Aid kit with required components, and locked area for medication storage. 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.

Component III was completed during today's visit and a copy was emailed to the applicant for future reference.

An exit interview was conducted, and a copy of this report was provided to Melayna Lagasca.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC809 (FAS) - (06/04)

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