198602863-12-18-2025-28-AS-BPEA-DPGVJN-20251218152901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602863
Report Date: 12/18/2025
Date Signed: 12/18/2025 03:29:21 PM

Document Has Been Signed on 12/18/2025 03:29 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	HOUSE OF GRACE 2		FACILITY NUMBER:	198602863
ADMINISTRATOR/ DIRECTOR:	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:	12/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Rebecca Sinclair - Co-Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 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) Bennette Pena conducted an unannounced Required-1 year visit. LPA met with Vanessa Arbis, Caregiver and Tito Riobuya, Caregiver and explained the purpose of the visit. At 1:50pm, Rebecca Sinclair, Co-Administrator arrived and assisted LPA with the inspection. The facility is licensed to serve six (6) non-ambulatory residents ages 60 years of age or older. The facility may retain a maximum of (6) hospice residents. LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tool and observed the following: Infection Control: Staff are adhering to infection control requirements. The staff use disposable gloves to clean and disinfect the high touched surfaces in the common areas. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility. Physical Plant/Environment Safety: The facility is a single-story home which consists of: living room with covered fireplace, dining area, kitchen, (3) bedrooms (3 residents and 1 staff), 3 bathrooms, laundry area, back yard, front yard and detached garage where part of it is used as caregivers bedroom. Resident bedrooms were inspected. The bathrooms are clean and operational. The hot water temperature was tested throughout the facility. Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. At approx. 1:30pm, readings were 140 deg F in bathroom #2 and 133.8 deg F in bathroom #2. At 2:30pm, LPA re-checked the hot water temperature and readings were 135.3 deg F in bathroom #2 and 130.7 deg F in bathroom #3. LPA observed sufficient food supply of (2) days of perishables and (7 days) of non-perishables. Knives, disinfectants, and cleaning solutions are kept locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguisher is fully charged and last serviced on 05/13/2025. The first-aid kit is fully stocked w/first-aid manual. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. A shaded area with outdoor furniture is provided in the back yard. The backyard is free of debris/hazards. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises. LPA observed part of the garage is being used as a sleeping room for staff. Operational Requirements: The facility accepts and retains residents with dementia. The plan of operation includes training for staff who provide dementia special care. Facility maintains liability insurance in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate which expires on 06/16/2026. According to the co-administrator, the facility does not handle cash resources for the residents. ***REPORT CONTINUED ON LIC809-C***

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOUSE OF GRACE 2	FACILITY NUMBER: 198602863
	VISIT DATE: 12/18/2025

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
26
27
28
29
30
31
32

Food Service: The kitchen was inspected and sufficient food supplies of 2 day perishable and a week of non-perishable are observed. Pesticides and cleaning supplies are kept away from the food preparation areas.
Incidental Medical Services: Residents medications were reviewed. The facility does not use the Medication Administration Record (MAR) or other type of documentation log to document medications given. Medications were stored in a locked cabinet and inaccessible to residents.

Due to time constraints, the annual continuation will be conducted at a later time.

There were deficiencies found during today’s inspection. Deficiencies are cited on the attached LIC809D.
Exit interview was conducted with and a copy of this report was provided to Rebecca Sinclair, Co-Administrator.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3