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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603555
Report Date: 08/17/2023
Date Signed: 08/17/2023 04:17:25 PM

Document Has Been Signed on 08/17/2023 04:17 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:CIRCLE OF GRACE, INC.FACILITY NUMBER:
198603555
ADMINISTRATOR:KHACHATRYAN, ANNAFACILITY TYPE:
740
ADDRESS:7157 HIDDEN PINE DRTELEPHONE:
(818) 425-6797
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 6CENSUS: 6DATE:
08/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Diana Castellanos, CaregiverTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza generated this Case Management - Deficiencies report in conjunction with complaint control # 28-AS-20230814181129 pertaining to observations made during file review. The purpose of the report was explained telephonically to Administrator Anna Khachatryan.

Administration staff received an email directive from resident (R1's) conservator asking staff to ban phone calls from one of R1's adult children. However, per file review Conservatorship court documents specify the conservatee's /(R1's) keeps the right to receive visits from family and friends, and does not specify that phone calls from family and friends shall be banned.

Per ASSEMBLY BILL 937 (Wieckowski), Chapter 127, Statutes of 2013,....a licensee may not violate a conservatee resident’s personal rights, including, but not limited to, the right to receive visitors, telephone calls, and personal mail at the request of a conservator, unless specifically limited by a court order.

Deficiency is cited.

An exit interview was conducted and a copy of the report and appeal rights were issued to staff Diana Castellanos.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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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Document Has Been Signed on 08/17/2023 04:17 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/17/2023 at 03:41 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: CIRCLE OF GRACE, INC.
FACILITY NUMBER: 198603555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2023
Section Cited
CCR
87468.1(a)(14)

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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. This requirement was not met evidence by:
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Adminsitrator agreed to submit a plan of correction that includes:

1. Proof of meeting with R1's conservator
2. Staff training/log in regulation 87468.1
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Based on record review and interviews conducted, R1's conservator instructed staff to ban incoming phone calls from one of R1's adult children. However, conservatorship has not expressly taken the right away from R1; which poses a potential health and safety risk to persons in care.
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
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