<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412123
Report Date: 08/30/2023
Date Signed: 08/30/2023 05:05:43 PM


Document Has Been Signed on 08/30/2023 05:05 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:GRACEVILLE ESTATEFACILITY NUMBER:
336412123
ADMINISTRATOR:MARLON HERMOSILLAFACILITY TYPE:
740
ADDRESS:79870 BARCELONA DRIVETELEPHONE:
(760) 345-0183
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:6CENSUS: 6DATE:
08/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Carol Madrid - AdministratorTIME COMPLETED:
05:16 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) Sara Martinez conducted an unannounced visit regarding complaint 18-AS-20230829141530 and met with Administrator Carol Madrid.

LPA conducted a health and safety check and toured the home, conducted interviews, and record review.

LPA conducted a health and safety check and found based on record review, observations, and interviews, that Staff One (S1) Staff Two (S2) and Staff Three (S3) was not associated to work at this facility. Civil penalties will be issued.

LPA conducted record reviews for both staff and residents and found the facility does not have staff files at the facility and the resident files for all six residents were not complete and contained blank Admission Agreements for all 6 residents, four out of six residents had their Physicians Report in the file. Incomplete files for residents in care does not meet Title 22 regulations and a deficiency will be issued along with a plan of correction.

LPA observed during a tour of the facility that Resident Two (R2) had multiple spots of blood on mattress which does not meet Title 22 regulations. A deficiency will be issued along with a plan of correction.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


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: GRACEVILLE ESTATE
FACILITY NUMBER: 336412123
VISIT DATE: 08/30/2023
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
26
27
28
29
30
31
32
During investigation of complaint 18-AS-20230829141530, LPA's record review and interviews revealed that facility did not report Resident One (R1) hospitalization on 08/21/2023. Reporting requirements state the licensee has seven days to report any incidents or events with resident and as of 08/30/2023, Licensee has not reported the hospitalization which does not meet Title 22 regulations. A deficiency will be issued.

Based on LPA’s observations, interviews, and record reviews, a deficiency will be issued and civil penalties assessed per California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted where a copy of this report, LIC809D, civil penalties, and appeal rights was provided to administrator Carol Madrid.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/30/2023 05:05 PM - It Cannot Be Edited

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: GRACEVILLE ESTATE
FACILITY NUMBER: 336412123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2023
Section Cited
CCR
87355(e)(2)

1
2
3
4
5
6
7
87355 CRIMINAL RECORD CLEARANCE (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance...
1
2
3
4
5
6
7
Licensee will have the three staff members associate to the facility by agreed POC date 08/31/2023. Civil penalty will be assessed.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on file review & interview, the licensee did not ensure S1, S2, and S3 was associated to the facility prior to working. Which is an immediete health and safety risk and/or personal rights violation to residents in care.
8
9
10
11
12
13
14
Type B
09/06/2023
Section Cited
CCR87468.1(a)(2)

1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe...comfortable...furnishings and equipment.
1
2
3
4
5
6
7
Licensee will purchase a new mattress and submit proof of purchase by the agreed plan of correction date 09/06/2023.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on observation and interview the licensee did not ensure a clean and safe mattress for R2. LPA observed multiple blood spots on the mattress which is poses a potential health and safety risk and/or personal rights violation to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 08/30/2023 05:05 PM - It Cannot Be Edited

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: GRACEVILLE ESTATE
FACILITY NUMBER: 336412123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2023
Section Cited
CCR
87506(a)

1
2
3
4
5
6
7
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirment was not met based on:
1
2
3
4
5
6
7
Licensee will read the regulations for what is needed in resident file for each resident in care and will fill out the required forms and documents for all six residents. Licensee will send proof of correction to LPA by the agreed due date 09/06/2023.
8
9
10
11
12
13
14
Based on observation, interview and record review, the Licensee did not ensure that resident files for all residents in care were available at the facility and complete. LPA observed multiple resident files with incomplete forms and blank admission agreements which poses a potential health, personal rights, and safety risk for residents in care.
8
9
10
11
12
13
14
Type B
09/06/2023
Section Cited
CCR87412(a)

1
2
3
4
5
6
7
87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:... This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to obtain the staff records and have them at the facility. Licensee will email LPA proof of records for all staff working by the agreed POC date 09/06/2023
8
9
10
11
12
13
14
Based on records review, observations, and interview, it was found that staff records were missing for all staff members except for the Licensee. LPA informed administrator and administrator stated they do not have the files at the facility. This poses a potenital health, saftey or personal rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 08/30/2023 05:05 PM - It Cannot Be Edited

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: GRACEVILLE ESTATE
FACILITY NUMBER: 336412123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2023
Section Cited
CCR
87211(a)(1)

1
2
3
4
5
6
7
REPORTING REQUIREMENTS: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following: (1) A written report shall be submitted to the licensing agency...within 7 days of the occurrence of any of the events...
1
2
3
4
5
6
7
Licensee will submit proof of training to staff for reporting requirments and will submit a statement to LPA the Licensee has read the regulations by the agreed plan of correction date 09/06/2023.
8
9
10
11
12
13
14
This requirement was not met, as evidenced by: Based on interviews and record review, the Licensee didn't ensure R1's hospitalization was reported to the Licensing agency.This poses a potential risk to the health, safety or personal rights of the residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5