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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604432
Report Date: 09/17/2024
Date Signed: 09/18/2024 07:52:05 AM


Document Has Been Signed on 09/18/2024 07:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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: 4DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Helenita PenolaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Julie Penola. Administrator Helenita Penola later arrived to meet with LPA. According to the facility’s license, the facility is licensed for six (6) non-ambulatory residents. Facilities current census is four (4).

LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected resident bedrooms. Facility was clean, sanitary, and in good repair. Resident bedrooms contained the required furnishings. Extra linens and hygiene supplies were present. Hot water temperature was in compliance.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on premises.

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher and first aid kit present. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff/residents and reviewed multiple staff/resident files. The files which LPA reviewed contained all required documents.

No deficiencies were cited during today's annual inspection.

An exit interview was conducted with 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) 767-2306
LICENSING EVALUATOR NAME: Alyssa RamirezTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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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