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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426107
Report Date: 11/15/2024
Date Signed: 11/15/2024 12:00:58 PM

Document Has Been Signed on 11/15/2024 12:00 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: 25DATE:
11/15/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator, Nkechi AnwuliTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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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 were 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. The time frame for a POC inspection had passed, therefore the deficiencies were re-cited on 11/06/2024 with a new POC due date of 11/07/2024. The following was observed during the time of the visit:

The following deficiencies were corrected by the POC due date and were corrected at the time of the visit:

Deficiency was cited under California Code of Regulations Title 22 82072(a)(1) Personal Rights on 11/06/2024. 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 and provide a training date by 11/07/2024. The administrator agreed to send documentation of training conducted with a behaviorist by the POC due date 11/07/2024. The administrator stated they would terminate S1 and send paperwork of the termination and disassociation by POC due date 11/07/2024.



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 11/07/2024. The administrator stated they would terminate S1 and paperwork of termination and disassociation would be sent by POC due date 11/07/2024.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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: 11/15/2024
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Deficiency was cited under California Code of Regulations Title 22 82072(a)(1) Personal Rights on 11/06/2024. 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 and send training material by POC due date 11/072024. 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 and evaluation for September 2024 and October 2024 by the POC due date of 11/07/2024.

POC visit was conducted 11/06/2024, and LPA confirmed with the administrator that the LPA had received the written plan for S2’s evaluations, Training conducted with all staff on client behaviors along with training materials used, training on personal rights conducted with S2, Staff evaluations for September 2024 and October 2024 for S2, Termination paperwork for S1, and CPI training completion certificates for all staff.

As of today’s date, 11/15/2024 disassociation for S1 was received. Review of the Guardian Roster on today’s date 11/15/2024 confirmed S1 is still associated to the facility.During today’s visit the administrator revealed they had not disassociated S1 from the Guardian as they were unable to gain access to Guardian website. During the time of the visit. Licensee provided LPA a written statement to disassociate S1, and submitted an access form to Guardian.

Therefore, the POC’s have been cleared during the time of the visit and a clearance letter was given to the Licesnee. An exit interview was conducted where this report was provided.

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

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
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