361881256-2-15-2022-18-AS-MBRN-CBNRTC-20220215121808

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881256
Report Date: 02/15/2022
Date Signed: 02/15/2022 12:18:35 PM

Document Has Been Signed on 02/15/2022 12:18 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	AGING GRACE SENIOR LIVING FACILITY LLC		FACILITY NUMBER:	361881256
ADMINISTRATOR:	MARTIN, BRITTANY		FACILITY TYPE:	740
ADDRESS:	11539 HAWTHORNE AVENUE		TELEPHONE:	(760) 508-8421
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	6	CENSUS: 0	DATE:	02/15/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Britanny Martin		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Melody Brown arrived at the facility 02/15/2022 at 09:15 AM announced in order to complete a Prelicensing Inspection for the above facility. LPA Brown met with Applicant/Administrator Brittany Martin. Administrator/Applicant Britanny Martin has applied for Residential Care Facility for the Elderly. The Fire Safety Inspection was approved on 12/16/2021 for six (6) ambulatory residents. LPA Brown observed the following: Structure: Facility was a one-story house with (3) resident bedrooms, one (1) staff room/office, two (2) resident/staff bathroom, living room, two (2) activity room, dining area and kitchen. There was an attached two (2) car garage in the right side of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Each resident bedroom #1, #2, #3 will accommodate ambulatory resident and one (1) staff bedroom/office. Three (3) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke and carbon monoxide alarm. Bathrooms: The (2) resident/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. At 11:15 AM, LPA Brown tested the water temperature in the resident bathroom. LPA Brown verified water temperature was measured at 113 degrees Fahrenheit. No garbage can observe with tight cover. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

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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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: AGING GRACE SENIOR LIVING FACILITY LLC	FACILITY NUMBER: 361881256
	VISIT DATE: 02/15/2022

NARRATIVE

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Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA Brown observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all residents. Laundry room with washer and dryer and laundry detergents and cleaning supplies were observed locked away from residents.

Living/Activity room:
There was a living/activity room with adequate seating for all residents and a working TV.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence with hygiene supplies but no caddy hygiene supplies for each resident.

Yards/Outside:
One (1) Patio furniture for outdoor seating observed. There is a gate/door on the right side with exit into the front of the house. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted near the entry hallway. No Let-Us-No poster observed, no Ombudsman Poster and no space for Family Councils Provided in a prominent Bulletin Board.

General items:
Three (3) fire extinguisher were charged and located in the kitchen, hallway and activity room. Two (2) carbon monoxide alarms and seven (7) smoke detectors were tested and were observed to be in working order. Resident records will be stored in a locked filing cabinet in the office. First Aid kit with required components but no First Aid Book, and locked area for medication storage was observed. LPA Brown observed a facility phone and it was operational. There is enough Emergency water supply observed and no required 72-hour emergency supply bag. Component III was completed on this day as well.
(CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC809 (FAS) - (06/04)

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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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AGING GRACE SENIOR LIVING FACILITY LLC	FACILITY NUMBER: 361881256
	VISIT DATE: 02/15/2022

NARRATIVE

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Pre-Licensing is incomplete and the following deficiencies to be resolved by 03//10/2022 at 09:30 AM:
Obtain and post Let-Us-No poster
Obtain and post an Ombudsman poster
Space for Family Councils provided on a prominent Bulletin Board.
Emergency Supply Bag(s) foreach resident
Personal Hygiene Supplies in a caddy for each reident
Personal Protective Equipment Supplies (PPE) - gown, face shield, N95 masks and surgical masks, gloves
Garbage can with tight cover in bathrooms
Print and Post Covid-19 Signages
Post Visitor Policy Procedure
Temp/Covid-19 Symptoms Questions Logs
Visitor Vaccination Verification Log

A follow up Pre-Licensure LIC809 will be generated upon resolution of deficiencies.

An exit interview was conducted where this report (LIC 809) was discussed and provided to the Administrator/Applicant Brittanty Martin..

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC809 (FAS) - (06/04)

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