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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400567
Report Date: 10/16/2024
Date Signed: 10/16/2024 01:16:53 PM

Document Has Been Signed on 10/16/2024 01:16 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/
DIRECTOR:		SUTJININGSIH, SRIADIFACILITY TYPE:
735
ADDRESS:997 W. GROVE STREETTELEPHONE:
(909) 874-6711
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 4CENSUS: 3DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Sriadi SutjiningsihTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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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 Sriadi Sutiiningsih, and discussed the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (4) and a current census of (3). The facility is a certified Inland Regional Center (IRC) vendor. During today's inspection, all three (3) clients were attending program. 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 has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space for clients in care. The facility is equipped with smoke/operating carbon monoxide alarms, fully charged fire extinguisher, laundry equipment, and telephone service. The facility has a sufficient supply of towels and hygiene products for clients in care. Four (4) client bedrooms were equipped with beds, bed linen, nightstands, chairs, and bedroom lighting. Client bathrooms were operating in safe conditions. The hot water in client bathrooms tested at 108 and 110 degrees F. LPA observed there were no emergency night lights in the hallway leading to client's bathroom. A deficiency cited. Sharps, disinfectants and cleaning supplies were store in a locked cabinet. LPA observed the facility has posted: Community Care Licensing complaint poster, emergency telephone numbers, evacuation sketch, activities, weekly menu and facility license. The facility has an infection control plan, client registry, and current insurance. LPA observed the facility did not have a current disaster and emergency plan, the plan on file was several years old. A deficiency cited.

Food Service: The facility’s dining and kitchen areas were maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care.

Health Related Services: Client medication are centrally stored in a locked cabinet. LPA observed client #1 (C1) AM medication was not logged when given to the client. The Licensee stated that medication was provided to the client. A deficiency cited.

Personnel/Client Records: Four (4) staff records were reviewed for health screenings, criminal record clearances, and first aid/CPR training certifications. Four (4) client records were reviewed for admission agreements, medical assessments, needs and service plans, and personal/incidental logs (P&I).

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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 7
Document Has Been Signed on 10/16/2024 01:16 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/16/2024 at 12:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by not maintaining a emergency night lights in hallways leading to client's bathroom; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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The Licensee shall submit proof to the licensing agency of night lights by POC due date.
Type B
Section Cited
CCR
80075(b)(5)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by not recorded/logged when Client#1 (C1's) AM medication was given; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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The Licensee shall submit to the licensing agency a statement of understanding of regulation cited by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 10/16/2024 01:16 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/16/2024 at 12:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by not obtaining a current disaster plan on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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The Licensee shall provide a current disaster plan to the licensing agency by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


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: SRI ENTERPRISES GRACEFUL HOUSE
FACILITY NUMBER: 366400567
VISIT DATE: 10/16/2024
NARRATIVE
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Deficiencies were cited and technical advisories were issued in accordance with Title 22 of the California Code of Regulations. An exit interview was conducted, where this report was discussed and a copy was provided with appeal rights to the Licensee at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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