<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426107
Report Date: 03/21/2024
Date Signed: 03/21/2024 06:05:25 PM

Document Has Been Signed on 03/21/2024 06:05 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: 25DATE:
03/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
07:58 AM
MET WITH:LEAD CAREGIVER, OSSEH GIBSONTIME COMPLETED:
09:28 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On March 21, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to the facility to conduct a case management visit. LPA Mixson was greeted and granted entry by Caregiver, Folake Oladukun and explained the purpose of today's visit, and later met with the Lead Caregiver, Osseh Gibson.

LPA Mixson spoke with the Lead Caregiver, via the telephone, and explained the purpose of the visit. LPA Mixson requested and received pertinent documents.

LPA Mixson toured the facility with the Lead Caregiver who arrived shortly after the LPA. Currently there are 25 clients at the Day Program and four staff. LPA Mixson made observation pertaining to another matter.

LPA Mixson observed facility utilities to be on and operating without issue. There was enough staff present at the facility to provide care and supervision. LPA Mixson assessed the available rooms where resident activities are held and there were no staff alone with clients in any of the small activities rooms.

There were no Health and/or Safety concerns observed during this visit and no deficiencies were cited.

An exit interview was conducted, and a copy of this report was provided to the Lead Caregiver, Osseh Gibson.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1