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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400567
Report Date: 10/16/2023
Date Signed: 10/16/2023 01:01:12 PM

Document Has Been Signed on 10/16/2023 01:01 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: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:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Sriadi Sutjiningsih, AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the SRI Enterprises Graceful House unannounced to conduct an Annual Inspection. LPA met with Administrator, Sriadi Sutjiningsih and Staff Member, Joe Kasmijan introduced self and stated purpose of the visit. LPA was granted entry and provided space to work. LPA was informed three residents in care were currently at their programs for the day.

LPA conducted a tour of the facility, inside and outside, and observed the following:

Facility: The facility includes 3 resident bedrooms, 1 staff room, kitchen, living room, den, 2 bathrooms, backyard and attached garage. The facility is vendorized by the Inland Regional Center at level 2. The facility is licensed for four, (4) ambulatory adults. The facility is operating at the capacity and in the conditions approved by Community Care Licensing (CCL).
Physical Plant: LPA Coleman observed the facility's temperatures to be comfortable. The lighting and lamps make for appropriate lighting to ensure residents to ambulate comfortably and safety. The facility is equipped with smoke alarms, carbon monoxide detectors throughout the premises. These were tested and found operational. The fire extinguishers were observed to be fully charged, and last inspected May 2023. LPA Coleman reviewed the facility's Emergency Disaster Plan and Fire Drills and observed that the facility last conducted a Fire Drill on September 2023. LPA observed no pool or bodies of water on facility grounds.
Interior and exterior pathways were free of clutter and unobstructed.
Food Service: Nonperishable and perishable food is sufficient for number of residents in care. Food is being prepared and stored properly. Facility has a variety of food available and accessible to residents in care. Sharp objects and chemicals are kept secure under the kitchen sink cabinet.
Care & Supervision: Facility has sufficient care staff; who assist residents 24 hours and 7 days a week. According to staff records, all staff files contained verification of all required annual training.
Record Review and Resident/Staff Files: LPA Coleman reviewed records for three, (3) residents currently living at the facility. Resident records are complete with Physician's Reports, Needs and Services Plans and Individual Program Plans. LPA reviewed two, (2) staff files and confirmed that staff records included current
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2023
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 2
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: SRI ENTERPRISES GRACEFUL HOUSE
FACILITY NUMBER: 366400567
VISIT DATE: 10/16/2023
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CPR/First Aid Certification and Criminal Record/Fingerprint Clearance. The Administrator's Administrator Certificate was observed in good standing.
Administration: Disaster/Evacuation Plan, Ombudsman poster, Administrator Certificate, Personal Rights and facility license are posted throughout the facility. Emergency Disaster Plan is current.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and locked in a file cabinet in the kitchen area. LPA reviewed 3 residents' medication lists. Centrally Stored Medication Log. LPA Coleman did not observe any medication errors at time of visit.

No deficiencies were observed or cited during this inspection. Exit interview conducted and copy of this report was provided to Sriadi Sutjiningsih.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC809 (FAS) - (06/04)
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