361881041-5-8-2026-56-AS-RHEZ-DTVQJM-20260508121258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881041
Report Date: 05/08/2026
Date Signed: 05/08/2026 12:13:51 PM

Document Has Been Signed on 05/08/2026 12:13 PM - 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GRACIOUS LIVING		FACILITY NUMBER:	361881041
ADMINISTRATOR/ DIRECTOR:	KAO, ANGEL		FACILITY TYPE:	740
ADDRESS:	2141 N EUCLID AVE		TELEPHONE:	(626) 622-0671
CITY:	UPLAND	STATE: CA	ZIP CODE:	91784
CAPACITY: 6		CENSUS: 4	DATE:	05/08/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Administrator Jesus Correa		TIME VISIT/ INSPECTION COMPLETED:	12:25 PM

NARRATIVE

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Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Hernandez met with Administrator Jesus Correa. The capacity is (6) current census is (4). The facility is a six (6) bedroom, two and a half (2 1/2) bathroom home with a kitchen/dining area, living room and attached garage. The facility is Residential Care Facility for the Elderly (RCFE). LPA Hernandez was accompanied by Administrator Jesus Correa to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Hernandez inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Hernandez observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. There was a designated storage space for resident/staff files. There is a Medicine cabinet with the resident’s medications locked. LPA observed scissors, knives, and chemicals kept unlocked accessible to residents in care. Deficiency will be issued.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has sufficient number of staff to provide care and supervision to the residents in care.

**Continuation on LIC809-C**

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Raquel Hernandez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACIOUS LIVING	FACILITY NUMBER: 361881041
	VISIT DATE: 05/08/2026

NARRATIVE

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Record Review: LPA Hernandez reviewed two (2) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA observed two (2) residents medications. LPA observed no updated centrally stored medication log for Resident #1 (R1) and Resident #2 (R2). Deficiency will be issued. LPA observed no reapprasial's for Resident #1 (R1) and Resident #2 (R2). Deficiency will be issued. Additionally, LPA observed no needs and services plan for R1 and R2. Deficiency will be issued. LPA Hernandez reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) test result. No issues were observed.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Jesus Correa.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Raquel Hernandez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/08/2026 12:13 PM - It Cannot Be Edited

Created By: Raquel Hernandez On 05/08/2026 at 11:36 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GRACIOUS LIVING	FACILITY NUMBER: 361881041
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not ensuring a centrally stored medication log was updated and completed for Resident #1 (R1) and Resident #2 (R2), which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/15/2026
	Plan of Correction
1 2 3 4	Administrator stated to send updated and completed centrally stored medication log by Plan of Correction (POC) due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:

	Raquel Hernandez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 05/08/2026 12:13 PM - It Cannot Be Edited

Created By: Raquel Hernandez On 05/08/2026 at 11:36 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GRACIOUS LIVING	FACILITY NUMBER: 361881041
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(e)(2)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not ensuring R1 and R2 have a completed needs and services plan, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/15/2026
	Plan of Correction
1 2 3 4	Administrator stated to send LPA updated needs and services plan for R1 and R2 by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:

	Raquel Hernandez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC809 (FAS) - (06/04)

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