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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423877
Report Date: 04/04/2022
Date Signed: 04/04/2022 02:58:19 PM


Document Has Been Signed on 04/04/2022 02:58 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:
04/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Melayna Lagasca, CaregiverTIME COMPLETED:
03:10 PM
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Licensing Program Analysts (LPAs) Tricia Danielson and Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220228173307 to check on the health, safety, and welfare of residents in care. LPA met with Melayna Lagasca and explained the purpose of the visit.

Three (3) of three (3) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well.
Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
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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