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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881040
Report Date: 02/24/2021
Date Signed: 02/24/2021 11:21:29 AM

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:GRACIOUS LIVINGFACILITY NUMBER:
361881040
ADMINISTRATOR:KAO, ANGELFACILITY TYPE:
740
ADDRESS:312 W ASTER ST.TELEPHONE:
(626) 622-0671
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:6CENSUS: 4DATE:
02/24/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee/Administrator Angel KaoTIME COMPLETED:
11:20 AM
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On 02/24/2021 Licensing Program Analyst (LPA) Javina George conducted an announced visit for the purpose of conducting a pre-licensing inspection.
Upon arrival LPA met with Licensee/Administrator Angel Kao whom assisted with the inspection. The facility is a single story house with 4 resident bedrooms, 1 staff bedroom, 2 bathrooms, living room, kitchen, backyard, and laundry room.

On 11/10/2020, the San Bernardino County Fire Department approved the facility for 5 non-ambulatory and 1 bedridden resident.

During today's inspection, LPA toured the interior and exterior of the facility. The medications will be centrally stored and locked in a closet located next to the resident's bathroom. The smoke and carbon monoxide detectors are operable. There was 1 fully charged fire extinguisher observed.

All cleaning supplies are locked in a cabinet located in the laundry room. The sharps and knives will be stored in a drawer, inside of the kitchen below the microwave. All doors, and passageways are clear from obstruction and were equipped with a light suitable to illuminate the hallways. The facility is also equipped with flash lights . There is a fireplace located in the living room that is screened. All beds have the required linen and supplies. There was a sufficient amount of clean linen and hygiene items stored in hallway and garage.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021
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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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: GRACIOUS LIVING
FACILITY NUMBER: 361881040
VISIT DATE: 02/24/2021
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The hot water was tested and ranged from 115.2-116.9 degrees F. All kitchen appliances operate properly. The shared resident bathroom is equipped with grab bars and non-skid floor mats and/or surfaces.

All garbage cans have tight fitting lids. The facility is stocked with a 2-day supply of perishables and a 7 day supply of non-perishable food items. The facility was stocked with dishes, tableware, and utensils in good repair and enough for the capacity. The resident files are stored in the medication closet. Facility staff files are stored at an alternate facility in the staff office. However there is a computer that staff can access staff documentation remotely if needed. LPA observed the emergency disaster plan, facility sketch, personal rights, and theft and loss policy, PUB 475 complaint poster hung on a cork board inside of the laundry room.

There was adequate seating in the common areas. There is 1 stocked first aid kit with 1 manual. The facility is stocked with activities; such as bingo, puzzles and karaoke to provide entertainment and encourage socialization for the residents, they are located in the living room. The facility also offers activities tailored to the resident interest and utilize online resources to access crossword puzzles., and coloring pages.

An exit interview was conducted, and a copy was at the facility with Licensee/Administrator's Angel Kao.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021
LIC809 (FAS) - (06/04)
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