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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700317
Report Date: 08/26/2020
Date Signed: 08/26/2020 10:13:18 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GRACE HOME IIFACILITY NUMBER:
342700317
ADMINISTRATOR:ESGUERRA, JULIOFACILITY TYPE:
740
ADDRESS:9260 LOMA LANETELEPHONE:
(916) 607-6225
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:24CENSUS: 23DATE:
08/26/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Julio Esguerra, AdministratorTIME COMPLETED:
10:15 AM
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Licensing Program Analysts (LPAs) Sabrina Calzada and Michael Hood met with Administrator Julio Esguerra to conduct a case management visit regarding recent relocation of resident "R1." LPAs wore M-95 masks upon entering and temperatures were taken before entering facility. LPAs explained purpose of today's inspection.

LPAs observed resident watching TV in the front room with other residents. Resident stated that she was doing fine. LPAs observed resident's bedroom and observed that she had the necessary accommodations in her room. LPAs observed a 2-day perishable and 7-day non-perishable food supply at the facility. Administrator stated that he had all medications for resident and has at least a 30-day supply. Administrator stated that resident is slowly adjusting and facility will reach out to conservator with any concerns.

LPAs observed a sufficient supply of PPE, including gloves and masks. LPAs observed Administrator, Licensee, and one staff member not wearing masks upon entering. LPAs explained the importance of the COVID-19 precautionary measures. LPAs observed COVID-19 signage throughout facility.

There are no deficiency being issued at this time. Exit interview conducted. A copy of this report was provided to facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 243-4743
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2020
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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