336412123-9-14-2023-18-AS-KBAG-CVNNG4-20230914102630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336412123
Report Date: 09/14/2023
Date Signed: 09/14/2023 10:26:36 AM

Document Has Been Signed on 09/14/2023 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GRACEVILLE ESTATE		FACILITY NUMBER:	336412123
ADMINISTRATOR:	MARLON HERMOSILLA		FACILITY TYPE:	740
ADDRESS:	79870 BARCELONA DRIVE		TELEPHONE:	(760) 345-0183
CITY:	LA QUINTA	STATE: CA	ZIP CODE:	92253
CAPACITY:	6	CENSUS: 5	DATE:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Marlon Hermosilla		TIME COMPLETED:	10:40 AM

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) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that five (5) clients live at this facility. There were two (2) staff members present. The Caregiver, Joseph Espinueva conducted and Administrator, Marlon Hermosilla completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Two (2) record were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Marlon Hermosilla, Administrator’s certificate expiration date is 11/01/2024. (Continued on LIC809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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: GRACEVILLE ESTATE	FACILITY NUMBER: 336412123
	VISIT DATE: 09/14/2023

NARRATIVE

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(Continuation from LIC809)

Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen.

Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 77 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 108.0 degrees F. Laundry is done in the garage. There is a locked cabinet for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is two (2) secured fireplaces at this facility. There is not a pool at the facility. There are one (1) gate that have a self-latching lock on the northeast side of the house. The facility performed their last fire and emergency drills on July 20, 2023. LPA reviewed the facility’s last disaster drills, which met the department's requirements. LPA observed emergency supplies and first aid with the required components.

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.

(Continued on LIC809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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: GRACEVILLE ESTATE	FACILITY NUMBER: 336412123
	VISIT DATE: 09/14/2023

NARRATIVE

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(Continuation from LIC809)

Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed if they were dispensed accurately.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed eight (8) dual fire alarms and carbon monoxide detectors. The caregiver tested the smoke alarms and carbon monoxide alarms on site. There is two (2) fire extinguisher on site, it was bought on 04/11/2023.

Pursuant to the Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to the Administrator, Marlon Hermosilla.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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