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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881041
Report Date: 02/24/2021
Date Signed: 02/24/2021 04:57:48 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:GRACIOUS LIVINGFACILITY NUMBER:
361881041
ADMINISTRATOR:KAO, ANGELFACILITY TYPE:
740
ADDRESS:2141 N EUCLID AVETELEPHONE:
(626) 622-0671
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY:6CENSUS: 5DATE:
02/24/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Angel KaoTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Jennifer Semin conducted a pre-licensing inspection via FaceTime. LPA met with Licensee/Administrator, Angel Kao. The application is for a Residential Care Facility for the Elderly for six (6) non-ambulatory residents one (1) of which may be bedridden, and a hospice waiver for 2 (two).
A tour of the pending facility was conducted inside and out. Overall, the pending facility is clean and of newer construction. The backyard has a pool that is properly fenced and gated and is inaccessible to residents. There are no firearms or ammunition. LPA observed the bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers and tubs have grab bars and non-skid mats. The water temperature was measured in the resident’s restroom between 105-120 degrees Fahrenheit. LPA observed food storage and preparation areas are clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. LPA observed a seven (7) day supply of nonperishable food and a two (2) day supply of perishable food. All appliances are clean and operating properly. There is a sufficient supply of linens, towels and personal hygiene items. The first aid kit was reviewed; all items are present including a First Aid Manuel. LPA observed a minimal supply of recreation and leisure items and activities, Ms. Kao states she plans to add a variety of recreation and leisure items based on their resident’s preferences. The backyard is completely enclosed with functioning gate to exit to front yard. Outdoor space is suitable for resident use that includes a covered patio, multiple tables and chairs. LPA observed the fire extinguishers to be recently serviced and completely charged. Smoke alarms and carbon monoxide detectors are present and functional. Medications are centrally stored and secured in a locked cabinet. All hazardous materials such as, cleaning and disinfecting supplies, knives and other sharps are locked and inaccessible to residents. All required forms are posted in a common area.
All pre-licensing requirements are met, facility is ready for licensure.
An exit interview was conducted where this report was discussed and provided to Ms. Kao via email.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
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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