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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530020
Report Date: 08/04/2022
Date Signed: 08/04/2022 11:41:28 AM

Document Has Been Signed on 08/04/2022 11:41 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:GRACEFUL LIVING SPACEFACILITY NUMBER:
365530020
ADMINISTRATOR:WHITE, CHARLOTTEFACILITY TYPE:
735
ADDRESS:17936 MONROE CTTELEPHONE:
(310) 696-3935
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 0DATE:
08/04/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Charlotte White- LicenseeTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Ryan Gardner conducted an announced visit to the facility for purpose of conducting a Pre-Licensing evaluation. An initial application to operate an Adult Residential Facility was submitted to the Central Applications Unit (CAU) for a total capacity of 4 non-ambulatory clients. Fire Clearance was granted 6/17/2022. LPA met with applicant Charlotte White. LPA Gardner observed the following:

Structure: Facility was a single-story house with four (4) client bedrooms, two bathrooms, living room, dining area, and kitchen area.

Heating/Cooling System: Central heating and air conditioning systems. Facility is maintained at a comfortable temperature.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by thermometer read by LPA at 111.8 F.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.

Bedrooms: All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm.



Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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
, CA 92507
FACILITY NAME: GRACEFUL LIVING SPACE
FACILITY NUMBER: 365530020
VISIT DATE: 08/04/2022
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Linens and Hygiene Supplies: An adequate supply of linens was available.

Firearms: The facility has one (1) firearm in a locked safe in a locked room adjacent to the garage. The firearm has a lock on the gun as well.

Yards/Outside: The backyard was completed was a patio with adequate covered area for providing shade. There were no obstructions. There is an above ground pool secured with a fence meeting the regulation requirements.

Garage: Laundry area with washer and dryer were located near the garage entry. Laundry detergents and cleaning solutions were secured in cabinets above the laundry machines. Garage was organized and free of obstructions.

Emergency Phone Numbers and Exit Plan: Let-Us-No poster, Ombudsman poster and client’s rights are posted, COVID-19 and hand washing postings. Visitor screening and sign procedures are in place.

General items: Smoke detectors and carbon monoxide detectors tested and working. LPA Gardner observed a facility phone, and it was verified to be operational by LPA.

LPA reviewed COMPONENT III with the applicant during this Pre-Licensing Inspection. This facility physical plant is prepared for licensure at this time.


An exit interview was conducted, and this report was discussed and provided to Licensee Charlotte White.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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