366400567-7-30-2026-56-AS-LFAW-DWGVVE-20260730164613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366400567
Report Date: 07/30/2026
Date Signed: 07/30/2026 04:46:29 PM

Document Has Been Signed on 07/30/2026 04:46 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SRI ENTERPRISES GRACEFUL HOUSE		FACILITY NUMBER:	366400567
ADMINISTRATOR/ DIRECTOR:	SUTJININGSIH, SRIADI		FACILITY TYPE:	735
ADDRESS:	997 W. GROVE STREET		TELEPHONE:	(909) 874-6711
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY: 4		CENSUS: 0	DATE:	07/30/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:55 PM
MET WITH:	SUTJININGSIH, SRIADI, ADMINISTRATOR		TIME VISIT/ INSPECTION COMPLETED:	04:55 PM

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On 7/30/2026 at 9:17 AM Licensing Program Analyst Attempted to conduct the required annual inspection visit. LPA knocked and rang door bell, no response. LPA left a voicemail message for Licensee. Licensee returned LPA call and LPA conducted a second visit today at 1:55 PM. LPA met with Licensee, Sriadi Sutiningsih, 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 (4). The facility is a vendorized by Inland Regional Center (IRC). During today's inspection, all four (4) clients were in attendance at the Day Program. LPA conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature 79 degrees F. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms and kitchen to be 105.9, 108.5 and 101 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. LPA observed medication closet to be locked and secured with medication, and first aid kit and book. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: The facility’s dining and kitchen areas were maintained and clean. The facility has sufficient amount of non-perishable and perishable food for number of clients in care. LPA observed one expired can good dated May 2026 and a loaf of bread that expired on July 29, 2026. Licensee removed items immediately and agreed to conduct another inventory of all food. A Technical violation issued.

Health Related Services: Clients medication are centrally stored in a locked cabinet. During today's audit of the clients MARs LPA observed that 1 out of 2 clients MARs was missing a initial for two (2) medications that were dispensed and one medication was still in the bubble and had a initial on the MARs stating it was issued. A Deficiency cited.

Nedra Brown
Lavette Farlow
	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SRI ENTERPRISES GRACEFUL HOUSE	FACILITY NUMBER: 366400567
	VISIT DATE: 07/30/2026

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Personnel/Client Records: LPA reviewed three (3) staff records for health screenings and TB test, criminal record clearances, and first aid/CPR and training. Two (2) client records were reviewed for admission agreements, medical assessments/needs and service plans, and personal/incidental logs (P&I). Based on LPA's observation staff and client records appears to be accurate and maintained.

During today's visit one deficiency and one technical violation was cited in accordance with Title 22 of the California Code of Regulations. An exit interview was conducted, where this report LIC809, LIC809C, and LIC9102TV and appeal rights were discussed and a copy was provided to the Licensee, Sriadi Sutjiningshi, and Administrator, Victor Subandhi at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/30/2026 04:46 PM - It Cannot Be Edited

Created By: Lavette Farlow On 07/30/2026 at 04:04 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: 07/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(k)(7)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and record review, the licensee did not comply with the section cited above in 1 out of 2 clients in care by not ensuring that all clients medication is dispensed properly, and removed from the bubble pack, and all medication dispensed is initial or an explanation for why the medication was not issued which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2026
	Plan of Correction
1 2 3 4	Licensee and Administrator agrees to conduct a training on medication and common medication errors with all staff. Submit a statement of understanding acknowledging that they have reviewed and understand the regulation cited by POC due and send proof to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:

	Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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