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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426107
Report Date: 08/30/2024
Date Signed: 08/30/2024 01:08:55 PM

Document Has Been Signed on 08/30/2024 01:08 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GRACE ADULT DAY CAREFACILITY NUMBER:
336426107
ADMINISTRATOR/
DIRECTOR:		ANWULI, NKECHIFACILITY TYPE:
775
ADDRESS:24318 HEMLOCK AVENUE #F-1TELEPHONE:
(951) 565-0663
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 30CENSUS: 29DATE:
08/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Director, Nkechi AnwuliTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility for a case management. LPA met with... who was informed of the purpose of the visit. LPA conducted a walk through and interviews.

The department received an incident report for Client #1 (C1), regarding staff #1 (S1) hitting and yelling at C1 on 7/23/2024 while in the bathroom.

LPA conducted (9) staff interviews. (5) staff reported not having information on the incident. (2) staff interviews confirmed S1 was heard yelling at C1 to get up while S1 was in the bathroom. (1) staff revealed S1 was spoken to about the incident and revealed they "tapped" C1 when in the bathroom. S1 was interviewed which revealed conflicting information, initially S1 reported not touching or tapping C1, but later stated C1 was repositioned on the toilet when they slipped off. S1 denied they hit or yelled at C1. LPA conducted (4) client interviews, the clients were unable to provide information on the incident.

Based on the interviews conducted, LPA found that (2) staff confirmed S1 had yelled at C1 while in the bathroom. Therefore, staff did not treat C1 with dignity and respect. California Code of Regulations Title 22 is being cited, and a plan of correction was created collaboratively with Nkechi Anwuli. An exit interview was conducted where this report was reviews, along with LIC809 D page, and appeal rights.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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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Document Has Been Signed on 08/30/2024 01:08 PM - It Cannot Be Edited


Created By: Janira Arreola On 08/30/2024 at 12:17 PM
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: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2024
Section Cited
CCR
82072(a)(1)

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(a) Each client shall have personal rights which include...(1)To be accorded dignity in his/her personal relationships with staff and other persons.This requirment was not met as evidenced by:
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Director agreed to conduct staff training with all staff with a behaviorist on managing client behaviors and send proof of this training by 9/30/2024.
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Based on staff interviews it was found that S1 had yelled at C1 while in the restroom. This poses an immediate, health safety or personal rights risk to clients.
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Director agreed to Train S1 on personal rights with a behaviorist and implement staff evaluations every month, for the first (6) months and will suspend staff if any futher personal right volations occur. Director will submit this plan in writting by the POC due date.

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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:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
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