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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880954
Report Date: 06/08/2023
Date Signed: 06/08/2023 09:46:30 AM


Document Has Been Signed on 06/08/2023 09:46 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
SAN BERNARDINO, 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: 7DATE:
06/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Taryn Kelley- CaregiverTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management visit during complaint visit, control number 56-AS-20221019115107. LPA met with Caregiver Taryn Kelley and explained the reason for the visit. At the time of the visit, there were seven (7) residents, and one (1) staff present.

During today visit, LPA toured the facility. During facility tour, LPA discovered that the facility has seven (7) beds and is providing care to seven (7) residents. LPA explained to Kelley that this is a violation of the facilities approved fire clearance and poses an immediate risk to the residents in care. LPA spoke via telephone to Administrator Jessica Velazquez during the visit. Velazquez stated that they were aware that they were not allowed to have seven (7) residents living at the facility.

Based on observations today, one (1) type A deficiency was cited per Title 22, Division 6, of the California Code of Regulations. Along with a $500-dollar immediate civil penalty for violating the facilities fire clearance.


An exit interview was conducted, and this report (LIC809) was discussed and provided Caregiver Taryn Kelley, along with a copy of LIC809D, LIC421IM, and the appeal rights.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
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 2


Document Has Been Signed on 06/08/2023 09:46 AM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GRACEFUL ASSISTED LIVING
FACILITY NUMBER: 361880954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2023
Section Cited
CCR
87202(a)

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87202 Fire Clearance. (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
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The licensee has agreed to read regulation 87202 entirely and send LPA self-certified letter that the regulation was read and understood. The licensee has agreed provide care for a maximum of six (6) clients and follow the limitations specified in their license.
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Based on interview, observation, and record review, the licensee did not comply with the section cited above evidenced by having seven (7) beds and providing care to seven (7) residents which is beyond the conditions and limitations specified in their license which poses an immediate health, safety, or personal rights risk to persons in care.
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The licensee has agreed to find new placement for one (1) of their residents in care, so the facility is complying with their approved fire clearance. POC is due by 6/9/2023.

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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: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2