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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426107
Report Date: 02/20/2024
Date Signed: 02/20/2024 10:50:18 AM

Document Has Been Signed on 02/20/2024 10:50 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:ANWULI, NKECHIFACILITY TYPE:
775
ADDRESS:24318 HEMLOCK AVENUE #F-1TELEPHONE:
(951) 565-0663
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 30CENSUS: 11DATE:
02/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee, Nkechi AnwuliTIME COMPLETED:
10:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola made an unannounced visit to the facility for an unrelated matter. During the visit, deficiencies were observed. LPA met with Licensee, Nkechi Anwuli, who was informed of the purpose of the of the visit.

LPA conducted a walk through of the facility, LPA observed the facility was in ratio. LPA observed cleaning supplies such as Clorox wipes and clean detergent in an unlocked room. LPA observed clients entering the room unsupervised with the unlocked chemicals. Therefore deficiency was issued for lack of locked cleaning supplies which are an immediate risk to clients in care.

An exit interview was conducted with the license, where this report along with deficiency page, and appeal rights were reviewed and provided to them.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2024
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 02/20/2024 10:50 AM - It Cannot Be Edited


Created By: Janira Arreola On 02/20/2024 at 10:34 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: 02/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2024
Section Cited
CCR
82087(a)(3)

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(a)(3) Disinfectants, cleaning solutions...and other items which could pose a danger...to clients shall be stored where inaccessible to clients.(A)Storage areas for poisons shall be locked.
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The licensee locked these items during the time of the visit. The licensee agreed to change procedure on placing these items in a locked area once they are purchased and received.
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Based on observation and interview, cleaning items were kept unlocked in a client room. This poses an immediate health saftey pr personal rights risk to residents in care.
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Written statement of this is due 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:Rikesha Stamps
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024


LIC809 (FAS) - (06/04)
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