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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881335
Report Date: 07/20/2022
Date Signed: 07/20/2022 10:26:24 AM


Document Has Been Signed on 07/20/2022 10:26 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:FOR HIS GRACE SENIOR CARE HOMEFACILITY NUMBER:
331881335
ADMINISTRATOR:NAVARRA, TERESAFACILITY TYPE:
740
ADDRESS:12537 POINSETTA DRTELEPHONE:
(951) 689-0182
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 1DATE:
07/20/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Melayna Lagasca, LicenseeTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conduct a case management visit, CCLD received notification from Licensee Melayna Lagasca will be closing the facility effective August 1, 2022 and eviction notices has been given to residents in care on June 1, 2022, CCLD to check on the health, safety, and welfare of residents in care. LPA met with Melayna Lagasca, Licensee. LPA was informed that one (1) resident currently resides at this facility and is currently in isolation for COVID-19 Positive. There were two (2) staff on duty during the time of the visit and one (1) minor child, brother of Licensee.

LPA observed all facility utilities to be on and operating without issue, resident in care. The facility has an adequate food supply and all residents have prescribed meds.

Based on the information obtained during today's visit, there are no deficiencies or citations being issued per California Health & Safety Code and Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with Licensee Lagasca and a copy of this report were provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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