<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604432
Report Date: 09/30/2021
Date Signed: 11/02/2021 11:16:29 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HOUSE OF GRACE FOR SENIOR CAREFACILITY NUMBER:
374604432
ADMINISTRATOR:PENOLA, HELENITA B.FACILITY TYPE:
740
ADDRESS:971 RUTGERS AVE.TELEPHONE:
(619) 407-7072
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:6CENSUS: 0DATE:
09/30/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Helinita PenolaTIME COMPLETED:
02:19 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kennedy conducted a Prelicensing/Component III visit to observe the physical plant for compliance. The LPA was met and granted entry into the facility by Helinita Penola, applicant. The LPA and Ms. Penola toured the physical plant and observed by the LPA were resident accommodations including furnishings, linens and personal hygiene items; resident bathrooms are equipped with non-skid flooring and paper towels, resident, staff and administrative records are to be located the locked medication closet;; food service including dishes, utensils, food storage and a seven day supply of nonperishables and a two day supply of fresh perishables are present; toxic substances are stored locked in a cabinet in the kitchen; medication storage and administration logs are located in locked closet first aid kit is locked in the medication closet; activities, supplies and sufficient space to conduct are present; smoke and carbon monoxide detectors are present and operable; facility posting are present in a common area and the facility administrator's certification is current; no pool or other body of water is present at the facility; per Ms. Penola, there are no guns, weapons or ammunition located on the property. Discussed with Ms. Penola were continuing operation requirements, record keeping and physical plant compliance. The following requirements need to be met prior to licensure: Water temperature needs to be within the required range; liability insurance needs to be acquired; a first aid manual needs to be acquired that meets requirements; non-discrimination policy needs to be posted; debris needs to be removed form the yard. Applicant will provide documentation of meeting these requirements to the LPA.

An exit interview was conducted with Helinita Penola, Applicant. A copy of this report along with Licensee Rights (LIC9058 01/2016) was provided to Ms. Penola via email. An electronic response confirms the documents were received.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna KennedyTELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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 1