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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426107
Report Date: 11/06/2024
Date Signed: 11/06/2024 10:25:36 AM

Document Has Been Signed on 11/06/2024 10:25 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 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: 23DATE:
11/06/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Nkechi AnwuliTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility to conduct a Plan of Correction (POC) Visit. LPA met with Administrator, Nkechi Anwuli who was informed of the purpose of the visit.

The purpose of this report is to document the POC’s that was agreed upon on 9/19/2024 for complaint control number 18-AS-20240809154836. This report also documents POC’s that were agreed upon on 08/30/2024 for a Case Management visit and investigation.

Deficiency was cited under California Code of Regulations Title 22 82072(a)(1) Personal Rights on 09/19/2024. Based on interviews and records review Staff #1 (S1) yelled at clients in care. POC was to renew Crisis Prevention and Intervention (CPI) training for all staff in October and send documentation to the LPA once completed. The administrator agreed to send documentation of training conducted with a behaviorist by the POC due date 09/20/2024. The administrator stated they would terminate S1 and paperwork of the termination would be sent by 09/20/2024 to the LPA.



Deficiency was cited under California Code of Regulations Title 22 82072(a)(3) Personal Rights on 09/19/2024. Based on interviews and records review S1 hit and threatened clients in care. POC was to send documentation on training conducted on personal rights by the POC due date of 09/20/2024. The administrator agreed to renew CPI training for all staff in October and send documented to the LPA once completed. The administrator stated they would terminate S1 and paperwork of termination would be sent by 09/20/2024.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 336426107
VISIT DATE: 11/06/2024
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Deficiency was cited under California Code of Regulations Title 22 82072(a)(1) Personal Rights on 08/30/2024. Based on interviews and records review Staff #2 (S2) had yelled at Client #1 (C1) while in the restroom. POC was to conduct training with all staff and a behaviorist on managing client behaviors and send proof of the training by 09/30/2024. The administrator agreed to train S2 on personal rights with a behaviorist and implement staff evaluations every month for the first (6) months. The administrator agreed to terminate S2 if any further personal right violations occur. The administrator agreed to submit this plan in writing by the POC due date of 08/31/2024.

On today’s visit, it was confirmed with the licensee that the LPA had only received the written plan for S2 but had not received the other agreed upon POC’s by the POC due dates of 08/31/2024 and 09/20/2024. During today's visit the administrator revealed the CPI training had not been conducted in October and new training date is due by the POC due date. Training material on client behavior's is due by the POC due date to verify the content of the training conducted.

The time frame for a POC inspection has passed, therefore the deficiencies will be re-cited on this report along with a new POC due date of 11/07/2024. The licensee was advised that if the POC’s are not received by 11/07/2024 civil penalties may be cited and will accrue until the POC is received.

An exit interview was conducted where this report along with the LIC809D page and appeal rights were provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 10:25 AM - It Cannot Be Edited


Created By: Janira Arreola On 11/06/2024 at 09:47 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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2024
Section Cited
CCR
82072(a)(1)

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(a) Each client shall have personal rights which include, but are not limited to, the following: (1)To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by…
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The administrator agreed to renew CPI training for all staff and provide a training date by the POC due date. The administrator agreed to conduct training with all staff and a behaviorist on how to manage client behaviors, training material used is due by the POC due date. The administrator agreed to train S2 on personal rights with a behaviorist. Proof of all training conducted is due by the POC due date.
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Based on interviews and records review, it was found that S1 and S2 had yelled at clients in care. This poses a immediate health safety or personal rights risk to clients in care.
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The administrator stated they would terminate S1 and send termination and diassociation paperwork by the POC due date. The administrator stated they would implement staff evaluations every month, for the first (6) months with S2 and would suspend staff if any further personal right violations occur. The administrator will submit S2’s staff evaluations to their LPA every month. Staff evaluations for September and October 2024 are due by the POC due date.
Type A
11/07/2024
Section Cited
CCR82072(a)(3)

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(a) Each client shall have personal rights...(3)To be free from corporal or unusual punishment, infliction of pain...intimidation...coercion, threat...or other actions of a punitive nature...This requirement was not met as evidenced by…
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The administrator agreed to conduct training with all staff and a behaviorist on personal rights and provide to the LPA by the POC due date. The administrator agreed to renew CPI training for all staff and provide a training date by the POC due date. The administrator stated they would terminate S1. Paperwork showing termination of S1 and disassociation will be sent by the POC due date.
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Based on interviews and records review, it was found that S1 had hit and threatened clients in care. This poses an immediate health safety or personal rights risk to clients in care.
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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


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