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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881041
Report Date: 11/13/2024
Date Signed: 11/13/2024 05:01:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2024 and conducted by Evaluator Yolanda Delgado
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241008134008
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:
11/13/2024
UNANNOUNCEDTIME BEGAN:
04:47 PM
MET WITH:Leofel Capulong, House ManagerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility provided information to an unauthorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced at the facility to conclude an investigation for the above allegation. LPA Delgado met with Leofel Capulong and explained the purpose of the visit. During the course of the investigation, LPA conducted interviews with Administrator, staff, and additional witnesses. LPA also conducted a review of pertinent documentation. LPA was unable to interview Resident #1 (R1) due to R1 passing away on March 17, 2024.

On October 8, 2024, Community Care Licensing received a complaint alleging that facility provided information to an unauthorized representative. It was reported that documentation pertaining to R1 was requested and R1’s and additional residents’ medical history was provided. It was alleged that Resident’s Power of Attorney, (POA) provided a written request to the facility in order to obtain R1’s

(Continued on Page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20241008134008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GRACIOUS LIVING
FACILITY NUMBER: 361881041
VISIT DATE: 11/13/2024
NARRATIVE
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(Continued from Page 1)

records on March 7, and March 10, 2024. Information obtained from Administrator indicated the request for records was sent on June 4, and June 6, 2024. LPA observed documentation that indicated records were sent to the requestor on May 30, 2024 and included information for Residents #2 (R2), Resident #3 (R3) and Resident #4 (R4), which the requestor was not authorized to receive. Administrator admitted that R2, R3, and R4’s confidential information was sent to the requestor and also corroborated that the requestor was not an authorized party to receive the documentation. Title 22 regulations state personal information shall remain confidential and to approve their release, except as authorized by law. This is a violation to the health and safety and or personal rights of clients in care.

Therefore, based on observations and interviews, the allegation that facility provided information to an unauthorized representative is SUBSTANTIATED. The facility will be cited for Title 22, Division 6, Chapter 8, Article 08, Section 87468.2 (a)(2).

An exit interview was conducted where this report, 9099-D, and appeal rights were discussed. Copies of the documents were provided to House Manager.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 56-AS-20241008134008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GRACIOUS LIVING
FACILITY NUMBER: 361881041
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2024
Section Cited
CCR
87468.2(a)(2)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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Licensee will ensure each document for a resident that is requested that it will be sent to the legal representative and conduct a secondary check prior to sending requests with management. Licensee will review regulation and email LPA a self-certifying statement of understanding and compliance of the regulation by POC due date.
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(2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not being met as evidenced by: R2, R3, R4's information was given to R1's representative whom is not a legal repesentative of R2, R3, and R4. This poses a potential health and safety risk.
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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.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3