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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423877
Report Date: 03/09/2022
Date Signed: 03/09/2022 12:17:16 PM


Document Has Been Signed on 03/09/2022 12:17 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 HOMEFACILITY NUMBER:
336423877
ADMINISTRATOR:MANUEL LAGASCAFACILITY TYPE:
740
ADDRESS:12537 POINSETTA DRIVETELEPHONE:
(951) 689-0182
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 3DATE:
03/09/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melayna Gubalane and R.J. CanentTIME COMPLETED:
09:47 AM
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Regional Manager (RM) Reyna Lacey, Licensing Program Manager (LPM) Deborah Mullen, and Licensing Program Analyst (LPA) Tricia Danielson met virtually via Microsoft Teams with Melayna Lagasca, daughter of deceased Licensee Manuel Lagasca and facility staff R.J. Canent to discuss the status of the facility, Ms. Lagasca's intentions regarding the operation of the facility, and to provide guidance in applying for re-licensure.
Ms. Lagasca reported she intends to take over operations of the facility and is moving forward as the designated Licensee. RM Lacey reviewed regulatory requirements and review of Health and Safety Code section 1569.193 with Ms. Lagasca. Ms. Lagasca has a background clearance and is currently associated to the facility. Ms. Lagasca was advised the following would be required to be submitted to the Department by March 23, 2022:
· a notarized statement, signed by the designee, acknowledging acceptance of designation of responsible party of the facility and proof of control of property.
· an application for licensure along with proof of Licensee Manuel Lagasca's death.

An exit interview was conducted, where this report was reviewed, and Ms. Lagasca was advised if she required assistance with the application to reach out to the LPA. A copy of this report was provided via email and a read receipt confirms receipt of the report. Ms. Lagasca has agreed to sign the report and returned a signed copy to LPA.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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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