<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881256
Report Date: 09/07/2022
Date Signed: 09/07/2022 09:38:56 AM


Document Has Been Signed on 09/07/2022 09:38 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:
(442) 316-3650
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 0DATE:
09/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Brittney Martin, LicenseeTIME COMPLETED:
09:40 AM
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) Rayshaun Nickolas conducted an announced visit to the facility for a case management visit, for the purpose of approving the facility's request for non-ambulatory status change. LPA Nickolas met with Licensee Brittany Martin who assisted LPA with conducting a tour of the facility.

Per the LIC200, the licensee submitted a change of status from ambulatory to non-ambulatory on 05/26/2022. The request was for six (6) non-ambulatory. A representative from the Fire Marshal conducted a fire safety inspection on 06/29/2022 and approved the change in status. During today’s visit, LPA Nickolas toured the facility and inspected bedrooms #1, #2 and #3. LPA Nickolas observed that bedrooms #1, #2, and #3 were in good repair and had the required furniture. LPA Nickolas observed bedroom # 1 with an exit door leading directly outside of the facility. LPA observed two additional emergency exit doors located on the opposite side of Bedroom #1. LPA Nickolas will be approving the Licensee's request to change from ambulatory to non-ambulatory status

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to Martin.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
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 1