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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366400567
Report Date: 05/09/2023
Date Signed: 05/09/2023 04:12:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/21/2023 and conducted by Evaluator Amber Coleman
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230321133917
FACILITY NAME:SRI ENTERPRISES GRACEFUL HOUSEFACILITY NUMBER:
366400567
ADMINISTRATOR:SUTJININGSIH, SRIADIFACILITY TYPE:
735
ADDRESS:997 W. GROVE STREETTELEPHONE:
(909) 874-6711
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:4CENSUS: 0DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Sriadi Sutjningsiah, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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The facility is not serving food of good quality and quantity to meet the resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Amber Coleman, arrived at the facility to deliver findings of the complaint investigation into the above listed allegations. LPA introduced self and stated purpose of the visit.

During staff interviews it was discovered, that grocery shopping occurs on a weekly basis. The last grocery trips were on the following dates: 3/16/23, 3/20/23 and 3/22/23. Residents are permitted to go along on the outing to the grocery stores. During this time, residents can ask for special/preferable items. Staff and residents both deny that food is denied when asked for. The facility policy is that the facility will pay up to $2.00 to assist the resident's should they come up short. While reviewing resident files, it was discovered that, there are currently no residents in care who have special diet restrictions.
Staff interviews also revealed that staff did not have an opportunity to check the resident's lunch to confirm it was appropriate to consume. As a result, the resident subsequently brought the moldy sandwich to day program. Please see LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20230321133917
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SRI ENTERPRISES GRACEFUL HOUSE
FACILITY NUMBER: 366400567
VISIT DATE: 05/09/2023
NARRATIVE
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Based on LPA's observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1), are being cited on the attached LIC 9099D.

An exit interview was conducted, where this report was discussed and then provided to Administrator, Sriadi Sutjningsiah.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230321133917
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SRI ENTERPRISES GRACEFUL HOUSE
FACILITY NUMBER: 366400567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
HSC
80076(a)(1)
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80076 Food Services (a) In facilities providing meals to clients...(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients.

This requirement is not met as evidenced by:
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Administrator agrees to remove can goods in the pantry. Review all can good's expiration dates and discard of can goods that are expired. Administrator will then submit a photo of all can good removed from pantry as well as a photo of the can goods in the pantry in good standing.
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Based on observation, interviews and record review, the Administrator did not confirm that can good kept in the facility's pantry were of good quality. Which poses a potential Health and Safety risk to the residents in care.
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It was agreed that the plan of correction could be completed and submitted to the Community Care Licensing Office within 7 business days.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3