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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530020
Report Date: 09/26/2024
Date Signed: 09/26/2024 06:21:40 PM

Document Has Been Signed on 09/26/2024 06:21 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GRACEFUL LIVING SPACEFACILITY NUMBER:
365530020
ADMINISTRATOR/
DIRECTOR:
WHITE, CHARLOTTEFACILITY TYPE:
735
ADDRESS:17936 MONROE CTTELEPHONE:
(310) 696-3935
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 1DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:45 PM
MET WITH:Charlotte WhiteTIME VISIT/
INSPECTION COMPLETED:
06:25 PM
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Charlotte White and discussed the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (4) and a current census (1). The facility is a certified Inland Regional Center (IRC) vendor. LPA conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility's swimming pool is fenced and observed locked. The facility has sufficient indoor and outdoor activity space for clients in care. The facility is maintained at a comfortable temperature of 74 degrees F. The facility is equipped with smoke/carbon monoxide alarms, night lights, laundry equipment and telephone service. The facility has a sufficient supply of linen and hygiene products for clients in care. Client bedrooms were equipped with beds, bed linen, nightstands, chairs, and bedroom lighting. Client bathroom equipment was operating in safe conditions. The hot water in client bathrooms tested at 112 degrees F. Firearms, sharps, disinfectants, and cleaning supplies were kept locked and inaccessible to clients. The facility has posted in a common area: facility license, personal rights, Community Care Licensing complaint poster, evacuation sketch, and emergency numbers.

Food Service: The facility’s dining area and kitchen were maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care. The facility's refrigerator tested at 37 degrees F and freezer temperature is maintained at zero degrees.

Health Related Services: The facility maintains records of client's medications and medications are centrally stored in a locked cabinet.

Personnel/Client Records: Staff records reviewed had health screenings, criminal record clearances, and first aid/CPR training certifications. Client records reviewed had admission agreements, IRC placement agreements, medical assessments, and needs and service plans. The Administrator's certification is current. The facility's liability insurance, earthquake drill training, emergency and disaster plan are current.

No deficiencies were cited during today’s visit. An exit interview was conducted, where this report was discussed and a copy was provided to the Administrator, at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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