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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880954
Report Date: 11/02/2021
Date Signed: 11/02/2021 04:02:49 PM

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:GRACEFUL ASSISTED LIVINGFACILITY NUMBER:
361880954
ADMINISTRATOR:VELAZQUEZ, JESSICAFACILITY TYPE:
740
ADDRESS:12253 SILVER ARROW WAYTELEPHONE:
(760) 508-2426
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:6CENSUS: 6DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Jessica VelasquezTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to conduct an annual inspection, with emphasis on infection control. LPA Brown was greeted and granted entrance by caregiver Vanessa Arriola and LPA Brown explained the purpose of today's visit. Caregiver Arriola accompanied LPA Brown on a tour of the inside and outside of the facility. Administrator Jessica Velazquez was contacted and arrived towards the end of the inspection.

During today’s visit, LPA Brown made observation pertaining to the facility’s current infection control measures. LPA Brown observed no screening area, and no temperature log kept by the facility where all temperatures for staff, residents and visitors are taken daily. LPA Brown will be issuing a Technical Assistance Advisory Note for no screening area and no temperature log kept by the facility. LPA Brown also observed proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and sufficient supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Throughout today's inspection, LPA Brown observed Administrator Jessica Velasquez to not wearing a mask. As of today's date, Community Care Licensing is still recommending for all staff to continue to wear a mask when inside the facility.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GRACEFUL ASSISTED LIVING
FACILITY NUMBER: 361880954
VISIT DATE: 11/02/2021
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LPA Brown will be issuing a Technical Assistance Advisory Note for staff not wearing masks while inside the facility. LPA Brown additionally observed a resident to not be wearing a mask either, and LPA Brown advised the Administrator to encourage the residents to wear masks when in common areas indoors, though they cannot be forced.

An exit interview was conducted with Administrator Jessica Velazquez and a copy of this report and LIC9102 TA Advisory Notes were provided.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6