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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412123
Report Date: 01/23/2024
Date Signed: 01/23/2024 09:49:44 AM


Document Has Been Signed on 01/23/2024 09:49 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 ESTATEFACILITY NUMBER:
336412123
ADMINISTRATOR:MARLON HERMOSILLAFACILITY TYPE:
740
ADDRESS:79870 BARCELONA DRIVETELEPHONE:
(760) 345-0183
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:0CENSUS: 6DATE:
01/23/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Marlon M HermosillaTIME COMPLETED:
10:10 AM
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On 01/23/24, Licensing Program Analyst, (LPA) Kathleen Banrasavong conducted an unannounced visit to the facility in order to conduct a case management pertaining to facility files. During a review of resident’s files on 01/16/24, LPA observed 1 out of the 4 resident’s records did not have signatures on the admission agreement. Due to the documents not being signed by Resident or Responsible Party as required, the facility will be issued a technical violation according to Title 22 regulations. There are no health and safety concerns at this time.

An exit interview was conducted, a copy of this report, a technical violation was provided to the Administrator, Marlon M Hermosilla, as evidenced by his signature.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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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