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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600979
Report Date: 10/23/2024
Date Signed: 10/23/2024 07:03:37 PM

Document Has Been Signed on 10/23/2024 07:03 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:GRATIA HOMEFACILITY NUMBER:
415600979
ADMINISTRATOR/
DIRECTOR:		LETRONDO, LILIBETHFACILITY TYPE:
735
ADDRESS:2585 WENTWORTH DRIVETELEPHONE:
(650) 580-1266
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 3DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Lilibeth LetrondoTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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On 10/23/2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with the administrator, Lilibeth Letrondo and explained the purpose of today's visit. House Manager, Veronica Cochon arrived shortly thereafter.

The facility is licensed for a capacity of 4 non-ambulatory residents of which 1 may receive hospice care services. Current census is 3 residents.
There were no residents under the care of hospice at this time.

LPA toured the facility inside and outside including the 4 private bedrooms, 2 full- bathrooms, kitchen, living room and common areas. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and in good condition. Facility temperature is comfortable. Hot water temperatures in the kitchen and bathroom was measured at 109- 115 degrees F. LPA observed 2-day perishables and 7-day non-perishables. Facility exits have audible devices installed.

Laundry room, located in the garage area, was observed to be locked.

Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.

LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors in the facility. Fire extinguishers were last inspected on 9/19/2024.

Central stored medication, toxins and sharps objects were observed to be locked and inaccessible to residents.

P& I were reviewed for 3 clients and LPA observed Records Of Client's/Resident's Safeguarded Cash Resources was incomplete as the column for Signature for Cash Transitions were not signed by the clients, or their responsible parties.

A review of (3) resident files was conducted and noted on the LIC 858.
A review of (3) staff files was conducted and noted on the LIC 859

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the administrator. A copy is provided and the appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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Document Has Been Signed on 10/23/2024 07:03 PM - It Cannot Be Edited


Created By: Murial Han On 10/23/2024 at 11:13 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: GRATIA HOME
FACILITY NUMBER: 415600979

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)(1)(A)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents

the client's full signature or mark, or authorized representative's full signature or mark, and a statement acknowledging receipt of the amount and date received,

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 3 out of 3 client's records of client's safeguarded cash resources were incomplete as it was not signed or marked by the clients or their responsible parties acknowledging receipt of the amount and date received which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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The administrator will develop a plan to ensure the clients or their responsible parties mark or sign the cash resources form acknowledging that cash was received. The administrator will provide a copy of the plan to CCL by 10/30/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
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