361881256-4-4-2024-56-AS-MECA-D3ZNNF-20240404103639

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881256
Report Date: 04/04/2024
Date Signed: 04/04/2024 10:36:45 AM

Document Has Been Signed on 04/04/2024 10:36 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
SAN BERNARDINO, 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:	(442) 316-3650
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	6	CENSUS: 5	DATE:	04/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:30 AM
MET WITH:	Brittany Martin- Administrator		TIME COMPLETED:	10:44 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	On 04/04/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with staff, Casey Kaler and introduced self and stated purpose of the visit. LPA was informed that there are currently 5 residents in care who are having breakfast in the dining room. The facility has 3 resident bedrooms, 2 resident bathrooms, 1 staff bedroom, kitchen, dining area, living room, 2 activity rooms, attached garage, and backyard with a shed. LPA completed a walk through of facility, review of records and medication audit. 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 of 70 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 105.2 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman, complaint poster and emergency disaster plans were posted in a common area. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed secured and inaccessible to residents. There are no guns or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. LPA observed a lock placed on the refrigerator unable to be opened without a key. Technical violation issued.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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

FACILITY NAME: AGING GRACE SENIOR LIVING FACILITY LLC	FACILITY NUMBER: 361881256
	VISIT DATE: 04/04/2024

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Yards/Outside: One shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard, and 1 shed used for storage. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed 5 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited at random and appeared to be predispensed by removing the daily dosage from its original container and placing it in a daily container by staff. Technical violation issued. The facility last conducted a fire drill on 02/20/2024.

Two technical violations and no deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC9102TV were discussed and copies were provided to the administrator, Brittany Martin who later arrived.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC809 (FAS) - (06/04)

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