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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400567
Report Date: 03/22/2023
Date Signed: 03/29/2023 03:06:00 PM

Document Has Been Signed on 03/29/2023 03:06 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: 3DATE:
03/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH: Sriadi Sutjningsiah, AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) conducted an unannounced complaint visit for complaint # 56-AS-20230321133917. During this visit, LPA observed a deficiency not related to the complaint allegations.

At approximately 2:50pm, while referencing the inside of the refrigerator, LPA observed a Children's Benadryl bottle on the top shelf of the refrigerator. LPA and Administrator discussed the medication and why it was present in the refrigerator. LPA also explained the impact and risks of having medications accessible to residents in care. Administrator stated she understood, then removed the medication from the refrigerator, then disposed of.

Based on today's observations made during the visit, deficiencies will be cited to address the concerns mentioned above. Deficiencies cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was reviewed and discussed, then provided to the Administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2023
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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Document Has Been Signed on 03/29/2023 03:06 PM - It Cannot Be Edited


Created By: Amber Coleman On 03/28/2023 at 10:27 AM
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: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2023
Section Cited
CCR
80075(j)(1)

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80075 Health Related Services
(j) Medications shall be centrally stored under the following circumstances:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the
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The plan of correction occured during the visit, Administrator removed the medication from the facility refridgerator and discarded of it. Administrator agrees to review the regulation and to submit a statement of understanding of the regulation by way of an LIC9098 with in the next 7 business days.
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centrally stored medication.
Based on observation, interviews and record review, the Adminsitrator did not ensure medication was made inaccessible to residents. Which poses an potential Health, Safety, or Personal Rights risk to persons in care.
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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:Nedra Brown
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023


LIC809 (FAS) - (06/04)
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