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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201955
Report Date: 03/21/2025
Date Signed: 03/21/2025 04:01:41 PM

Document Has Been Signed on 03/21/2025 04:01 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SENIORS WITH GRACE CARE HOMEFACILITY NUMBER:
415201955
ADMINISTRATOR/
DIRECTOR:		MANUEL, GRACEFACILITY TYPE:
740
ADDRESS:167 ALAMEDA DE LAS PULGASTELEPHONE:
(650) 369-5070
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 6CENSUS: 6DATE:
03/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Joel Santos, Caregiver/House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 3/21/2025, Licensing Program Analyst(LPA) John Calandra and Licensing Program Manager(LPM) Andrea Medlin arrived at the facility to conduct the Annual 1-year required inspection at 9:30AM. LPA Calandra and LPM Medlin were greeted by Joewel Santos, Caregiver/House Manager and explained the purpose of the visit. LPA spoke to Licensee/Administrator Grace Manuel over the phone and was informed she would not be able to join the visit.

LPA Calandra and LPM Medlin toured the physical plant. This is a 1-story building with 4 bedrooms and 3 bathrooms(2 for residents and 1 for staff), a living room, dining room, kitchen, and outdoor space/backyard. All bedrooms had the required furniture and sufficient lighting. No accessible bodies of water or hazards were observed in hallways or the backyard. The facility's fire alarms and Carbon Monoxide detector were observed to be in working order. The facility's first aid kit was observed to have all required items. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility was maintained at a comfortable temperature of 72 degrees Fahrenheit. The facility's hot water was measured between the required 105-120 degrees Fahrenheit. The facility's fire extinguishers were last serviced on 9/16/2024.

All sharp objects, poisons, and detergents were observed to be locked and in-accessible to persons in care.

LPA and LPM reviewed 6 resident records and 5 staff files. All were observed to be complete.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility.

LPA and LPM requested a copy of the updated LIC 500 (Personnel Summary Report) by 3/28/2025.

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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 3
Document Has Been Signed on 03/21/2025 04:01 PM - It Cannot Be Edited


Created By: John Calandra On 03/21/2025 at 11:15 AM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SENIORS WITH GRACE CARE HOME
FACILITY NUMBER: 415201955

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)5(B)
87608(a)5(B): Postural Supports: Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, facility is using full bed rails for R1 which is considered a restraint which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/22/2025
Plan of Correction
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Licensee/Administrator to remove full bed rail and submit photo as proof of correction to the Department by the POC due date.
Type A
Section Cited
CCR
87608(a)(3)
87608(a)(3): Postural Supports: A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and document review, facility does not have written orders from a physician indicating the need for half bed rails in the rooms of R2, R3, R4, R5, and R6, which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/22/2025
Plan of Correction
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Licensee/Administrator will call physicians and obtain written orders indicating the need for half bed rails. Licensee will also send copies of physicians orders to the department by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SENIORS WITH GRACE CARE HOME
FACILITY NUMBER: 415201955
VISIT DATE: 03/21/2025
NARRATIVE
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LPA and LPM received a copy of the Administrator's Certificate.

Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties.

An exit interview was conducted. This report was reviewed with Joewel Santos, Caregiver/House Manager and a copy of the report along with Appeal Rights left at the facility.

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
LIC809 (FAS) - (06/04)
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