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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426107
Report Date: 03/04/2024
Date Signed: 03/04/2024 11:31:24 AM


Document Has Been Signed on 03/04/2024 11:31 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:GRACE ADULT DAY CAREFACILITY NUMBER:
336426107
ADMINISTRATOR:ANWULI, NKECHIFACILITY TYPE:
775
ADDRESS:24318 HEMLOCK AVENUE #F-1TELEPHONE:
(951) 565-0663
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:30CENSUS: 25DATE:
03/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:ADMINISTRATOR, AMILAH GRAYTIME COMPLETED:
11:36 AM
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On March 04, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the Day Program unannounced to conduct the required annual inspection. LPA Mixson met with Amilah Gray, the Administrator, introduced herself, and stated the purpose of the visit. The Facility File review was conducted at the Regional Office and additional forms were requested and reviewed on site.

LPA Mixson toured the facility, along with Amilah, and inspected the inside and outside of the facility. The facility is a single-story building located at 24318 Hemlock Ave, # F-1, Moreno Valley, CA. 92557. The facility phone number is (951) 565-0663 and it is operable.

Physical Plant: The physical plant, is in good condition, neat, and orderly. Outdoor and indoor passageways are free of obstruction at the time of this visit. The Day Program activity rooms have the required furniture, such as tables, chairs, storage space, and sufficient lighting. The building temperature throughout was per regulations. The activity rooms are equipped with the required items, per Title 22. The hot water temperature was tested in several of the restrooms, in which they each tested within the range required per regulations. The restrooms were equipped with liquid soap and paper towels. LPA Mixson toured the kitchen which is for staff breaks and warming food only. The facility had activity schedules posted and available for review. The Day Program has emergency food and water. LPA Mixson inspected the common areas and small private rooms, and each was equipped with required furniture per regulations. The fire extinguisher was in the green and the program recently had a fire inspection in Feb. 2024. The red fire alarm boxes and lights were observed. The Day Program does not assist with medication or provide any snacks or meals. The facility sends the residents meals. The Day Program had a designated area for resident and staff files, and it was locked. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There was adequate seating in the common areas and sufficient space for activities. LPA Mixson observed monthly activity calendars. LPA Mixson reviewed several staff and resident files and conducted staff and resident interviews. LPA Mixson reviewed previous Community Care Licensing forms. There were no regulation violations observed or cited during today’s visit. An exit interview was conducted, and a copy of this report was provided to the Administrator, Amilah Gray.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
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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