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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881054
Report Date: 02/24/2021
Date Signed: 02/24/2021 01:05:20 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:
361881054
ADMINISTRATOR:KAO, ANGELFACILITY TYPE:
740
ADDRESS:349 E KENWOOD ST.TELEPHONE:
(626) 622-0671
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY:6CENSUS: 5DATE:
02/24/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Angel KaoTIME COMPLETED:
12:58 PM
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Licensing Program Analyst (LPA) Natalie Gayoso conducted an announced pre-licensing video conference inspection due to COVID-19. LPA met with administrator Angel Kao. The application is for a Residential Care Facility for the Elderly. Currently there are five (5) residents in care.

A tour of the facility was conducted inside and out. The facility is a five (5)bedroom, three (3) bathroom home with a living room, dining room, and kitchen. There are no pools, bodies of water, firearms, or ammunition. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. LPA observed the bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers, and tubs have grab bars and nonskid strips. LPA observed the applicant measuring the hot water temperature in the bathrooms. The water temperature measured 106 degrees F. There is sufficient supply of linens, towels, and personal hygiene items. LPA observed a recreation area with leisure items and activities. The back yard has a table and chairs with a patio cover for residents' use and observed to be fully fenced with an unlocked gate

LPA observed food and storage and preparation areas. Food preparation areas are clean and sanitary, and food is kept in a safe and healthful manner. Refrigerator and freezer are maintained at appropriate temperatures. The kitchen was observed to have dishes, silverware and pots and pans. All appliances are clean and operating properly. A washing machine and dryer are available and in working order. The homes smoke and carbon monoxide detectors were tested and verified to be in working order. A fire extinguisher was present and fully charged.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
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)
Page: 1 of 2
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: 361881054
VISIT DATE: 02/24/2021
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The first aid kit was reviewed; all items are present. 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. Medications are stored inaccessible to any unauthorized individuals. Secured areas are available for facility files and resident files

Pre-licensing inspection complete. Facility is ready for licensure.
An exit interview was conducted, and a copy of this report was reviewed and provided to Ms. Kao via email.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
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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