361881041-7-26-2021-18-AS-NBRN-C5MU7L-20210806152006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361881041
Report Date: 07/22/2021
Date Signed: 07/26/2021 03:13:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2021 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210519152239

FACILITY NAME:	GRACIOUS LIVING		FACILITY NUMBER:	361881041
ADMINISTRATOR:	KAO, ANGEL		FACILITY TYPE:	740
ADDRESS:	2141 N EUCLID AVE		TELEPHONE:	(626) 622-0671
CITY:	UPLAND	STATE: CA	ZIP CODE:	91784
CAPACITY:	6	CENSUS: 6	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	03:10 PM
MET WITH:	Angel Kao, licensee/administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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9

Illegal Eviction
Staff are not meeting the needs of the resident
Staff did not assist resident with incontinence appropriately

INVESTIGATION FINDINGS:

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On 7/26/21 Licensing Program Analysts (LPA) Shaunte Henry and Anna Bueno conducted an unannounced visit for the purpose of delivering the findings to the above allegations. The LPA met Angel Kao, explained the nature of the visit and was granted entry into the facility.

Resident 1 (R1) was given a 30-day eviction notice on 5/19/21. During a reappraisal, it was determined that R1 needed a higher level of care. The notice was provided to CCL as required. R1 received hospice services for a feeding tube and wound care. The family requested additional 1:1 care to be provided by the facility staff. The family of R1 refused to obtain a personal caregiver for R1. Documentation indicates that staff at the facility provided proper incontinence care for R1. Interviews with the licensee and the adminsitrator confirmed that Staff 1 (S1) provided proper incontience care to R1. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time. An exit interview was conducted where this report and LIC 811 were provided to Angel Kao.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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