198602863-10-24-2023-28-AS-CWOG-CWWQVW-20231024123100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602863
Report Date: 10/24/2023
Date Signed: 10/24/2023 12:33:36 PM

Document Has Been Signed on 10/24/2023 12:33 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	HOUSE OF GRACE 2		FACILITY NUMBER:	198602863
ADMINISTRATOR:	AGUIRRE, MICHELLE		FACILITY TYPE:	740
ADDRESS:	2815 MESA DRIVE		TELEPHONE:	(626) 716-1033
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 6		CENSUS: 6	DATE:	10/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Michelle Aguirre		TIME COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with Caregiver Maedna Arbis who allowed the entry of the facility and explained the purpose of the visit. Shortly after the administrator Michelle Aguirre arrived and assisted with the visit. The facility is licensed for residents ages 60 and over, may retain a maximum of four (4) hospice residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. All staff has an updated health screening in file. 2. Operational Requirements: The fire clearance is cleared for the facility for 6 non-ambulatory. Currently all residents are non-ambulatory and no one is bedridden. The facility has the sufficient amount for liability insurance covering injury to residents and guests. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($3,000,000) is in place. 3. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: Dining area, kitchen, sitting room, three residents bedrooms, two resident bathrooms, one guest bathroom, laundry room, live in staff room and a detached garage. Each resident bedroom has two beds, two drawers, required beddings and furniture and sufficient lighting and closet space. The two residents bathrooms are clean, sanitary and in a good working condition. Both bathrooms have the required grab bar and non-skid mat. The two bathrooms hot water temperature were tested between 114.1 and 1118.2 degrees F. which is within the Tittle 22 regulation. All the appliances in the kitchen and living room are working well. The sharp knives are stored in a locked kitchen drawer.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOUSE OF GRACE 2	FACILITY NUMBER: 198602863
	VISIT DATE: 10/24/2023

NARRATIVE

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All the cleaning supplies and chemicals are stored and locked in a cabinet in the laundry room. The linen and towels are stored in the hallway cabinet. The extra personal hygiene products are stored in the laundry room cabinet. The carbon monoxide detectors were inspected and they are working properly. The facility has patio with table and chairs for resident to utilize outdoor activity. The Passageway, walkway and patio are free of obstruction.

4. Staffing: Facility has sufficient staffing to provide care and supervision the residents.

5. Personnel Record and Training: All the staff files are stored and locked in the file cabinet near the kitchen care. All the staff in the facility are over 18 years old, fingerprint cleared and associated with the facility. All the staff has the required documents in their personnel files which include health screening, TB test result, required training hours and updated first aid certificate. The administrator is Michelle Aguirre and her administrator certificate expiration date on 08/28/2024.

6. Resident's Record-Incident Reports: The resident files are stored in the cabinet in the kitchen. LPA inspected all six (6) residents files and they all have the required documents which include face sheet, admission agreement, pre-appraisal, medication list and physician report with ambulatory status. Administrator reported that currently there's one new resident admission package is on the way by mail.

7. Resident's Right/Information: LPA observed the required posters posted along the hallway include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician.

8. Planned Activity : Sufficient space to accommodate both indoor and outdoor activities was observed. They do have event planner comes once a week. Also during the week, they do play bingo, music time and activity time with residents.

9. Food Service: The facility has sufficient 2 days perishable and 7 days non perishable food supply in the facility. All the food are stored properly in the facility. Currently the facility has one resident is on puree diet and LPA reviewed the doctor's order.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOUSE OF GRACE 2	FACILITY NUMBER: 198602863
	VISIT DATE: 10/24/2023

NARRATIVE

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10. Incidental Medical and Dental: The facility staff would arrange transportation for residents' medical and dental appointment if needed. LPA inspected all 6 residents medication and they are all centrally stored and they are stored in the locked medication cabinet. They all have 30 days supply of medication.

11. Disaster Preparedness: The facility has an updated emergency disaster plan (LIC610E) and the last fire drill was conducted on 09/2023. The facility has two alternative temporary shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training.

12. Residents with Special Health Needs: No residents in the facility with prohibited health condition. Currently there are four resident on hospice and two residents on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice.

Due to residents are at lunch and staff are busy serving them and LPA was not able to interview the residents and staff.

Exit Interview Conducted and a copy of the report was provided to administrator Michelle Aguirre.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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