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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600979
Report Date: 04/30/2024
Date Signed: 04/30/2024 07:37:22 PM

Document Has Been Signed on 04/30/2024 07:37 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
SF COASTAL AC/SC, 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:
04/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:15 PM
MET WITH:Administrator, Lilibeth LetrondoTIME VISIT/
INSPECTION COMPLETED:
07:50 PM
NARRATIVE
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On April 30, 2024, while Licensing Program Analyst (LPA) Murial Han was conducting an unannounced 10-day complaint visit, LPA received a tour of the facility that was conducted by the house manager and observe the following.

At 6:12PM, LPA observed the right doors of the 2 medication cabinets in the kitchen were unlocked and the chemicals underneath the kitchen sink were unlocked and accessible to residents in care.

The house manager was able to open the 2 right doors of the medication cabinets without a key and according to the house manager, the doors were supposed to be locked by a magnet and they were recently fixed.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed and reviewed with the administrator.

A copy of this report and the Appeal Rights is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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 04/30/2024 07:37 PM - It Cannot Be Edited


Created By: Murial Han On 04/30/2024 at 06:46 PM
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: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2024
Section Cited
CCR
80075(k)(1)

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80075 Health Related Services.. (k) The following requirements shall apply to medications which are centrally stored:..(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for..
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The administrator/Licensee will develop a plan to CCL to ensure that both doors on the medication cabinets are locked and inaccessible to residents in care at all times. The administrator/licensee will provide proof
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This requirement is not met as evidenced by based on observation and interview, the 2 right doors of the medication cabinets were unlocked which poses an immediate health risks to residents in care.
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that the doors are locked. The administrator/licensee will provide a copy of the plan to CCL and proof that the doors are locked by 5/1/2024.
Type A
05/01/2024
Section Cited
CCR80087(g)

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80087 Buildings and Grounds..(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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The administrator/Licensee will develop a plan to CCL to ensure that all chemical are locked and inaccessible to residents in care at all times. The administrator/licensee will provide proof
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This requirement is not met as evidenced by based on observation and interview, LPA observed the chemicals that are stored underneath the kitchen sink was unlocked which poses an immediate health and safety risks to residents in care.
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that the doors are locked. The administrator/licensee will provide a copy of the plan to CCL and proof to CCL by 5/1/2024.
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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