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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700317
Report Date: 07/09/2024
Date Signed: 07/09/2024 12:21:55 PM


Document Has Been Signed on 07/09/2024 12:21 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GRACE HOME IIFACILITY NUMBER:
342700317
ADMINISTRATOR:NELSON JACINTOFACILITY TYPE:
740
ADDRESS:9260 LOMA LANETELEPHONE:
(916) 607-6225
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:24CENSUS: 22DATE:
07/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Nelson Jacinto TIME COMPLETED:
12:30 PM
NARRATIVE
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On 07/09/24, CCL Staff, Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Talwinder Bains arrived to do a health and safety check. LPM and LPA met with Administrator, Nelson Jacinto (S1) and explained the purpose of today's visit.Upon arriving at the facility LPA, LPM and S1 toured the facility for areas but not limited to residents rooms, bathrooms, common areas, kitchen and outside areas. Following issues were observed during tour:

CCL staff observed the exterior gate of the facility had 3 points of entry. It was observed that 2 of the 3 gates had key pad locks and one gate with the key pad lock locked to another part of the gate. Licensee indicated the gates are locked so residents cannot AWOL from the facility. The facility is restricting resident's from entering and exiting the facility which was not allowed per Title 22 Regulations. Civil Penalties are being assessed today in the amount of $500.

Upon enter the facility, CCL staff observed there were no activity scheduled for residents and there were no activities calendar for residents. Additionally, the facility does not have a designated activities personnel per Title 22 regulations. During the facility tour is was observed that numerous resident's personal closets were found to be locked. Licensee indicated that only staff have access to the keys to the locks resulting in resident not having access to their personal belongings.

Resident Room #9 bathroom found to be in disrepair. The shower has a leak and is inoperable. The toilet is leaking and does not flush properly. The ceiling and wall of the bathroom has what appears to be water damage. On 06/20/2024, LPA Bains spoke to the licensee who stated the facility would ensure the bathroom would be fixed. As of this date, there were no follow up and the restroom is still inoperable. 2nd building resident's bathroom's mirror was found to be broken and not safe for resident's use.

During today's conversation with Licensee, the Licensee agrees to engage with the Department's Technical Support Program. The Department will submit a referral to TSP. Deficiencies issued are noted on the LIC809D per Title 22 Regulations. The Licensee has been reminded that failure to correct the deficiencies may also result in civil penalties. Exit interview conducted. Appeal rights were provided and copy of the report was provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
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 3


Document Has Been Signed on 07/09/2024 12:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GRACE HOME II
FACILITY NUMBER: 342700317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2024
Section Cited
CCR
87468.1(a)(6)

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87468.1 -Personal Rights of Residents in All Facilities -(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents....this requirement is not as evidenced by;

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Administrator shall submit a letter of understanding of this regulation and will train staff as well. Administrator shall ensure that all exits are accessible to residents at all times. All POC documents are due by 07/10/24.
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CCL staff observed that facility has locked front entry doors with padlocks which pose a immediate health and safety risks for residents in care.
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Administrator removed all padlocks from front entrance doors while CCL staff were present. Civil Penalties assess in the amount $500.
Type B
08/10/2024
Section Cited
CCR87219(e)

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87219(e)-Planned Activities -In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, shall have primary responsibility for the organization, conduct and evaluation of planned activities. ....this requiement is not met as evidenced by;
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Administrator shall submit a letter of understanding of this regulation to CCL and will appoint staff to do activities for residents by POC due date- 08/10/24.
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CCL staff observed that there were no schdueld activties for residents and there was no staff assigned to do activities as required per this regulation which poses a potential health and safety risks for residents 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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/09/2024 12:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GRACE HOME II
FACILITY NUMBER: 342700317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2024
Section Cited
CCR
87468(a)(13)

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87468(a)(13)- Personal Rights of Residents in All Facilities- (13)To have access to individual storage space for private use....this requirement is not met as evidenced by;

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Administartor shall submit a plan on how all resident's will be given full access to thier belongings at all times. Additionally, the Administrator shall submit a plan on how the facility will ensure resident's belongings are safeguarded. All POC documents are due by 07/10/24.
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CCL staff observed that residents personal belongings were locked in thier closet(s) and were inaccessible to residents which poses immediate health and safety risks for residents in care.
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**Administrator will provide all resident's who have locks on thier closets either the key to the locks or remove the lock, which ever the resident's request.**
Type A
07/10/2024
Section Cited
CCR87303(a)

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87303(a)- Maintenance and Operation-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.... this requiement is not as evidenced by;
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Administrator shall submit a work order and/or any documentations regarding the repair to bathroom #9. Administrator shall provide the Department with a timeframe of when work will be completed.
Plan shall be submitted by 07/10/2024 and will send proof to CCL upon completetion.
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CCL staff observed that resident room # 9 bathroom was not operating well and 2nd building resident's bathroom has broken mirror which poses immediate health and safety risks for residents 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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3