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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426107
Report Date: 04/13/2022
Date Signed: 04/13/2022 12:28:46 PM

Document Has Been Signed on 04/13/2022 12:28 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:GRACE ADULT DAY CAREFACILITY NUMBER:
336426107
ADMINISTRATOR:ANWULI, NKECHIFACILITY TYPE:
775
ADDRESS:24318 HEMLOCK AVENUE #F-1TELEPHONE:
(951) 565-0663
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 30CENSUS: 5DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Alvbertine DawsonTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA)'s, Janira Arreola, Chinwe Nwogene and Licensing Program Manager Joel Esquivel made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA's were greeted and granted entry by Program Coordinator, Albertine Dawson who was informed of the purpose of the visit. At the time of visit there were 3 staff and 5 clients present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA’s toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA's observed Covid-19 postings at the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer) in all restrooms (2 restrooms.)

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The facility also has a designated infection control lead and cleans and disinfects the highly touched surfaces during each shift, and as needed. LPAs observed sufficient PPE equipment at the facility.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GRACE ADULT DAY CARE
FACILITY NUMBER: 336426107
VISIT DATE: 04/13/2022
NARRATIVE
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LPA and Program Coordinator Observed the following deficiencies:


· There were two areas where exposed electrical outlets were noticed - area was the main activity room.
· Fire exit hallway leading to the parking lot was being used as storage area and as a result was not cleared for passage and was not properly lit.
· Accessible body of water was observed in one of the activity room. No supervision was observed in room.
· Cleaning supplies and chemicals were in accessible places in unlocked cabinets in 2 activity rooms.
· Clothes in unlocked drawer was described to be used for all clients - the facility did not have evidence that the clothing was laundered for the residents wellness and personal rights.
· Client file for C1 was not available for viewing at the facility.
· Observed several holes in wall in main hallway of the facility
· "Sanctuary Room" was identified at end of the main hallway and was not a main exit. "Sanctuary Room" was unlocked and accessible to clients which possess a potential health and safety risk.
· Facility did not have sufficient amount of incontinence supplies for incontinent client.

An exit interview was conducted, and a copy of this report was reviewed and provided to facility Assistant Administrator, Albertine Dawson as well as appeal rights.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 04/13/2022 12:28 PM - It Cannot Be Edited


Created By: Janira Arreola On 04/13/2022 at 10:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACE ADULT DAY CARE
FACILITY NUMBER: 336426107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 electrical outlets which were exposed in one of the client activity rooms. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Licensee will repair exposed electrical outlets by POC date. Licensee will submit proof by POC date.
Type B
Section Cited
CCR
82087(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with several holes located in the wall of the main hallway. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Licensee will repair holes in the main hallway by POC date and submit proof to LPA.
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 Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 04/13/2022 12:28 PM - It Cannot Be Edited


Created By: Janira Arreola On 04/13/2022 at 11:03 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACE ADULT DAY CARE
FACILITY NUMBER: 336426107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82020


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above based on obstruction of a fire exit leading out to a parking lot and absence of lighting. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Licensee will remove obstructions from fire exit and ensure proper lighting. Licensee will provide proof to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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 Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/13/2022 12:28 PM - It Cannot Be Edited


Created By: Janira Arreola On 04/13/2022 at 11:22 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACE ADULT DAY CARE
FACILITY NUMBER: 336426107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82072


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by posessing 3 drawers full of clothing that would be loaned to clients. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Licensee will remove loaner clothing and remove practice of using clothing for all residents. Licensee will provide evidence of removal by POC date.
Type B
Section Cited
CCR
82072(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not providing incontinent supplies to residents. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Licensee will purchase incontinent supplies for clients. Licensee will provide proof of purchase by POC date.
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 Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


LIC809 (FAS) - (06/04)
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