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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604432
Report Date: 10/31/2023
Date Signed: 10/31/2023 12:39:49 PM


Document Has Been Signed on 10/31/2023 12:39 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 DIEGO RO, 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:
(858) 294-3410
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:6CENSUS: 6DATE:
10/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Helenita PenolaTIME COMPLETED:
12:58 PM
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA identified himself and discussed the purpose of the visit with Administrator Helenita Penola. According to the facility’s license, the facility has a maximum capacity of six (6) residents, of whom six (6) can be non-ambulatory. Zero (0) may be bedridden and a hospice waiver approved for two (2) residents. During today’s inspection there were six (6) residents present.

LPA, accompanied by Administrator toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. Medications were labeled, as required, and stored in locked areas.



No pools or bodies of water on the premises. Per Administrator, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.


[CONTINUED ON LIC 809-C]
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HOUSE OF GRACE FOR SENIOR CARE
FACILITY NUMBER: 374604432
VISIT DATE: 10/31/2023
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LPA interviewed staff, resident and reviewed multiple staff and resident records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Helenita Penola to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC809 (FAS) - (06/04)
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