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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602863
Report Date: 07/06/2022
Date Signed: 07/22/2022 04:45:02 PM

Document Has Been Signed on 07/22/2022 04:45 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HOUSE OF GRACE 2FACILITY NUMBER:
198602863
ADMINISTRATOR:AGUIRRE, MICHELLEFACILITY TYPE:
740
ADDRESS:2815 MESA DRIVETELEPHONE:
(626) 716-1033
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 6DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Maedna Arbis TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with caregiver Maedna Arbis and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident files.

The facility is a single story house and located in a residential neighborhood area. The facility consists of living room, kitchen, dining room, two residents' bathrooms, four residents' bedrooms, staff bathroom, laundry room and a detached garage. All four residents bedroom were toured. Bedroom#1 has one bed, one chair, one drawer, required linen and furniture and sufficient lighting and closet space. Bedroom#2 to #4 has two beds, two drawers, required linen and furniture and sufficient lighting and closet space. All two residents bathrooms were toured and they are clean, sanitary and in a good condition. Bathrooms also have required grab bars and non-skid mats. The hot water temperature tested at the two residents bathrooms were between 133.1 and 138.0 which is beyond the required 105-120 degrees F. The refrigerator in the kitchen and garage and kitchen cabinet has sufficient food for two days perishable and seven days non-perishable. All the kitchen appliances are working properly. The knives and utensils are locked in the kitchen cabinet. The common areas such as living room and dining room are clean and have required furniture. All the cleaning supplies and chemicals are locked in the cabinet in the laundry room which is inaccessible for residents. The front and back yard are maintained well and the back yard has a shaded area and sitting area for residents to utilize. All the carbon monoxide detectors and smoke detectors are inspected and they are working well.

LPA reviewed 6 resident files to confirm emergency contact is updated. LPA was not able to review any staff file because there's no staff files were located in the facility. LPA reviewed 6 residents' medications. All medication are centrally stored and all residents medication seems adequate and up-to-date.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
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 07/22/2022 04:45 PM - It Cannot Be Edited


Created By: Christine Wong On 07/06/2022 at 02:13 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOUSE OF GRACE 2
FACILITY NUMBER: 198602863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2022
Section Cited

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87303 Maintenance and Opeartoon (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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The requirement is not met as evidenced by LPA's observation. LPA checked the two residents bathroom for hot water temeprature and its measured between 133.1 and 138 which is beyond the Title 22 regulation
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Type B
07/13/2022
Section Cited

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87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.

The requirement is not met as evidenced by
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By record review, all staff files were not maintained at the facility and LPA was not able to interview.
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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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022


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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOUSE OF GRACE 2
FACILITY NUMBER: 198602863
VISIT DATE: 07/06/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in each room and common area and facility is disinfected every shift and once a month for deep cleaning. The bathrooms have sufficient soap, paper towels, and signs. The PPE supplies are sufficient for more than 30 days.

The deficiencies cited are documented on the attached 809D. A copy of the report and appeal rights will be provided to caregiver
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC809 (FAS) - (06/04)
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