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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604909
Report Date: 10/16/2025
Date Signed: 10/16/2025 03:53:51 PM

Document Has Been Signed on 10/16/2025 03:53 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:GRACEFUL COTTAGE LIVING INC.FACILITY NUMBER:
374604909
ADMINISTRATOR/
DIRECTOR:		CASTRO, JANETFACILITY TYPE:
740
ADDRESS:3484 BONITA WOODS DRIVETELEPHONE:
(619) 856-4716
CITY:BONITASTATE: CAZIP CODE:
91902
CAPACITY: 6CENSUS: 0DATE:
10/16/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Applicant, Janet CastroTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an announced Pre-Licensing Inspection. The visit included a Component III orientation and a walk through of the facility's physical plant to evaluate compliance with Title 22, Division 6 of the California Code of Regulations and the California Health and Safety Code.

Upon arrival, LPA was greeted at the front entrance by Administrator, Janet Castro and granted entry after properly identifying herself and stating the purpose of the visit.

This facility applied to be licensed as a Residential Care Facility for the Elderly (RCFE). The fire clearance was approved on May 29, 2025, authorizing care for up to five (5) non-ambulatory adult residents and one (1) bedridden in room #1. Administrator stated she applied for hospice waiver and will follow-up with Centralized Application Bureau Analyst to make sure is added to the license. As of today’s visit, no residents are in care. The submitted facility sketch matched the current physical layout.

Facility Inspection
LPA, accompanied by Administrator, Janet Castro conducted an inspection of both the interior and exterior areas of the facility. The following observations were made:
· The facility was clean, sanitary, and in good repair.
· Required postings were displayed in visible locations.
· There was sufficient space and equipment to support laundry, visitation, meetings, and resident activities.
(continue at LIC809C)
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Marisela Garcia-Centeno
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2025
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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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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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: GRACEFUL COTTAGE LIVING INC.
FACILITY NUMBER: 374604909
VISIT DATE: 10/16/2025
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(continue from LIC809)
· Indoor and outdoor pathways were clear of obstructions and slip hazards.
· Smoke and carbon monoxide detectors, emergency lighting, and a facility telephone were operational.
· Fire extinguisher was purchased on May 21, 2025 and bore valid inspection tags.
· All chemicals and toxic substances were stored in locked areas, inaccessible to residents.
Bedrooms and Bathroom
· Client bedrooms were equipped with the required furnishings, allowed for easy passage, and had windows with intact screens.
· The facility had adequate linens and hygiene supplies available.
· Bathrooms (2) were equipped with non-skid mats and grabbars
· Toilet, sink, and one shower were fully functional.
· The facility's ambient temperature was comfortable and compliant.
· Hot water measured at 112°F, within the regulatory range.
Kitchen and Storage
· The kitchen contained appropriate cooking utensils and equipment.
· Knives and other sharp objects were securely stored in a locked cabinet.
· A 7-day supply of non-perishable and a 2-day supply of perishable food was stocked upon resident admission.
· Medications will be stored in a locked cabinet inside the facility.
· A complete first aid kit and manual were available in the medicine cabinet.
· Client and staff records will be stored in a locked cabinet.
Additional Observations
Per Castro, no firearms or ammunition are or will be stored on the premises.
Conclusion
LPA reviewed and discussed ongoing operational requirements, record keeping, reporting obligations, and physical plant standards with the applicant. All items reviewed were in compliance with applicable regulations.

The Pre-Licensing Inspection and Component III orientation were completed during today’s visit. The applicant was advised that the facility is ready for licensure, pending final review and approval by Licensing management. An exit interview was conducted with Castro, during which a copy of this report and the Licensee Appeal Rights (LIC 9058, 03/22) were provided. The signature below confirms receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Marisela Garcia-Centeno
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC809 (FAS) - (06/04)
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