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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881256
Report Date: 03/15/2022
Date Signed: 03/15/2022 10:15:42 AM


Document Has Been Signed on 03/15/2022 10:15 AM - 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
, CA 92507



FACILITY NAME:AGING GRACE SENIOR LIVING FACILITY LLCFACILITY NUMBER:
361881256
ADMINISTRATOR:MARTIN, BRITTANYFACILITY TYPE:
740
ADDRESS:11539 HAWTHORNE AVENUETELEPHONE:
(760) 508-8421
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 0DATE:
03/15/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator Brittany MartinTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Melody Brown conducted an announced pre licensing visit 03/15/2022 at 09:40 AM. This is an announced Pre-Licensing visit conducted with applicant/Administrator Brittany Martin who assisted in the tour of inside and outside of facility and the evaluation. LPA Brown made a second (2nd) announced prelicensing visit this date. The follow up visit was made to confirm that all corrections have been made.

The following: “Obtain and post Let-Us-No poster, Obtain and post an Ombudsman poster (poster will be issued to the facility once they have a resident), Space for Family Councils provided on a prominent Bulletin Board, Emergency Supply Bag(s) for each resident, Personal Hygiene Supplies in a caddy for each resident, 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.” All were found to be corrected on this visit date, 03/15/2022.

The facility was evaluated in accordance with the Title 22, California Code of Regulations (CCR). Based on the observations and evaluation of the facility this date, the facility’s ready for licensure.

Applicant/Administrator Brittany Martin will be notified once facility is licensed.

An exit interview was conducted, and a copy of this report (LIC 809) was discussed and provided with applicant Administrator Brittany Martin.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
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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