<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603109
Report Date: 03/14/2025
Date Signed: 03/14/2025 05:22:29 PM

Document Has Been Signed on 03/14/2025 05:22 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:GRACE BLOSSOM CAREFACILITY NUMBER:
198603109
ADMINISTRATOR/
DIRECTOR:		IKPEAMAEZE, LILIANFACILITY TYPE:
740
ADDRESS:20430 HARVEST AVETELEPHONE:
(951) 816-1077
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 6CENSUS: 5DATE:
03/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Caregiver Julie HunterTIME VISIT/
INSPECTION COMPLETED:
05:20 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
License Program Analysts (LPA) Luis De Leon conducted an unannounced annual required visit. LPAs met with Esther Araiza. Ms. Araiza called Administrator to inform of LPA visit. Administrator was not available at the time but requested Julie Hunter to help during visit. The purpose of today’s visit was explained to facility personnel met during this visit. Administrator Facility is licensed to serve six (6) non-ambulatory residents aged 60 and above of which 1 may be bedridden. Facility has a hospice waiver for 4 residents. Administrator. Administrator arrived and participated in visit.

The LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows:

FACILITY PHYSICAL PLANT
· Three (4) resident bedrooms, two (2) Full Bathroom, attached car garage, shaded outdoor area, living room, kitchen, and dining room, and front and back yard.

REVIEW OF FILES
· Resident Admission Agreements, Residents & Staff files, Staff fingerprint clearance, Medications, Staff First Aid Certificate, Consumer Needs and Service Plan.
· LPA reviewed three (5) staff files and four (5) Resident files.

Interview was conducted with two (2) staff and one (1) Resident. Other residents were sleeping or unable to respond to questions.

Continue on page 809C.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
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 4
Document Has Been Signed on 03/14/2025 05:22 PM - It Cannot Be Edited


Created By: Luis DeLeon On 03/14/2025 at 03:59 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: GRACE BLOSSOM CARE
FACILITY NUMBER: 198603109

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above 1 out 5 resident records. Resident 1 (R1) had PRN prescription (Furosemide 20 mg) was given to resident but there was no documentation. Resident 3 (R3) did not received medication as prescribed (Melatonin 5 mg) and did not include the exact dosage, the minimum number of hours between doses or the maximum number of doses allowed in each 24-hour period.
POC Due Date: 03/28/2025
Plan of Correction
1
2
3
4
Licensee will train staff on proper documentation for medication and administration of the same. Licensee will provide care licensing training plan and log of staff participating on training.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Fernando Fierros
LICENSING EVALUATOR NAME:Luis DeLeon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
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: GRACE BLOSSOM CARE
FACILITY NUMBER: 198603109
VISIT DATE: 03/14/2025
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
Observations during facility tour:

· Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPAs observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for residents.
· Wall and floors are in good repair. Hallways were clean and free of obstructions.
· Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food.
· Auditory devices were seen on exit doors which are required for dementia residents and were operating at the time of the visit.
· Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean.
· The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees.
· Sharps are locked in kitchen and inaccessible to residents. Also, disinfectants and cleaning supplies are locked and secured inaccessible to residents.
· Smoke detectors were observed in all bedrooms and carbon monoxide detectors was observed in living room around kitchen area. One (2) fire extinguishers were observed and were fully charged with last inspection on 7/23/24.
· Last fire drill and disaster drill was conducted on 1/17/25.
· Front and back yards are free of hazards and there were no bodies of water present at facility. Shaded area was available to residents.
· The medications are centrally stored and locked in a cabinet in kitchen. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all six (5) residents. Resident 1 (R1) had PRN prescription (Furosemide 20 mg) was given to resident but there was no documentation. In addition, two medications (Docusate Sodium 250 mg and Ferrous Sulfate 325 mg) had not been refilled. Resident 2 (R2) did not have medication on refilled (Memantine HCL 10mg, Vitamin D3 50 mg, Donepezil 5m). Resident 3 (R3) did not received medication as prescribed (Melatonin 5 mg).

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D pages. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/14/2025 05:22 PM - It Cannot Be Edited


Created By: Luis DeLeon On 03/14/2025 at 04:58 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: GRACE BLOSSOM CARE
FACILITY NUMBER: 198603109

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based record review, the licensee did not comply with the section cited above in 2 out of 5 resident's prescriptions which poses an immediate health, safety or personal rights risk to persons in care. Resident 1 (R1), two medications (Docusate Sodium 250 mg and Ferrous Sulfate 325 mg) had not been refilled. Resident 2 (R2) did not have medication refilled (Memantine HCL 10mg, Vitamin D3 50 mg, Donepezil 5m). Resident 3 (R3) did not received medication as prescribed (Melatonin 5 mg) on 4 days.
POC Due Date: 03/28/2025
Plan of Correction
1
2
3
4
Licensee will train staff to follow up with responsible parties to request medication refill. Licensee will provide training plan and staff list who participated for training.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Fernando Fierros
LICENSING EVALUATOR NAME:Luis DeLeon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4