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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603555
Report Date: 04/30/2024
Date Signed: 04/30/2024 02:34:50 PM

Document Has Been Signed on 04/30/2024 02:34 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/
DIRECTOR:		KHACHATRYAN, ANNAFACILITY TYPE:
740
ADDRESS:7157 HIDDEN PINE DRTELEPHONE:
(818) 425-6797
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 6CENSUS: 5DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:37 AM
MET WITH:Anna Khachatryan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to caregiver Roberto Rios. Administrator Anna Khachatryan arrived shortly after. There are currently 5 elderly residents 60 years and older residing in the facility. The following 12 Care Compliance and Regulatory Enforcement (CARE) tool domains were utilized during the inspection.

Infection Control:

  • The facility has an Infection Control Plan & COVID Mitigation Plan. Supplies of Personal Protective Equipment (PPEs) were observed.


Operational Requirements:
  • An Infection Control Plan has been added to the Plan of Operation.
  • The facility has a Dementia Waiver in place and an approved Hospice Waiver for 6 residents.
  • A fire clearance for 6non-ambulatory residents; of which 1 may be bedridden in room $4 is in place.
  • Liability Insurance in the amount of ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 5/30/2024.
  • An American Red Cross 1st Aid kit and manual are readily available.
  • No Surety bond is in place. Facility does not handle resident monies.


*Narrative continues next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CIRCLE OF GRACE, INC.
FACILITY NUMBER: 198603555
VISIT DATE: 04/30/2024
NARRATIVE
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Physical Plant/Environment Safety:
  • The facility is a single-story home located in a residential area consisting of six (6) bedrooms, two (2) full bathrooms, kitchen, dining room, living room, laundry room, rear shaded patio area, and attached garage. The facility has two (2) fully charged fire extinguishers. Smoke and carbon monoxide detectors are operational.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances in the unlocked laundry room were observed accessible to residents. A citation was issued.
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.
  • None of the resident beds had mattress pads. A citation was issued.
  • Residents (R3 & R5) have oxygen tanks in their rooms, but a a "No Smoking-Oxygen in Use" sign was not posted in appropriate area i.e., near the room door or at the facility entrance. A citation was issued.

Staffing:
  • A total of six (6) staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expires 3/8/2025.
  • Four (4) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was observed. Staff have criminal background clearance and training.

Resident Records/Incident Reports:
  • A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, Individual Service Plans, and medication records.
  • RCFE complaint poster and Personal rights were observed posted.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
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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: CIRCLE OF GRACE, INC.
FACILITY NUMBER: 198603555
VISIT DATE: 04/30/2024
NARRATIVE
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Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • An activity calendar is posted in the hallway. The facility does not have a Resident Council.

Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
  • One (1) resident has a physician order for modified diet.

Incident Medical and Dental:
  • Three (3) centrally stored resident medications were reviewed to verify there is a 30-day supply of medications. Resident (R1's) Irbesatan 300 mg & Alendronate Sodium 70 mg medications have not been refilled. A citation was issued.
  • Medical and dental transportation is provided.

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E was reviewed.
  • Records of resident Appraisal and Needs services plans are part of Emergency training.

Residents with Special Health Needs:
  • Three (3) residents are receiving hospice services. One (1) resident receives home health services.
  • Postural support physician orders are on file. Full and half bed rails for mobility assistance were observed in some resident rooms. No residents have prohibited health conditions.
  • Appraisals are on file.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Anna Khachatrya. A copy of the report and appeal rights will be emailed today due to printing difficulties.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/30/2024 02:34 PM - It Cannot Be Edited


Created By: Noemi Galarza On 04/30/2024 at 01:54 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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) 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
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2
3
4
Based on record review, the licensee did not comply with the section cited above in that resident (R1's) Irbesatan 300 mg & Alendronate Sodium 70 mg medications have not been refilled, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
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Administrator contacted the pharmacy to request medication refills.
1. Submit picture proof that medications were received.
2. Submit proof of staff training
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the laundry room had unlocked cleaning supplies/disinfectants and detergents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
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Administrator shall submit proof the deficiency was corrected. Administrator stated that a lock will be placed in the laundry room cabinet.
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: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/30/2024 02:34 PM - It Cannot Be Edited


Created By: Noemi Galarza On 04/30/2024 at 01:54 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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that residents (R3 & R5) have oxygen tanks in their rooms, and a "No Smoking-Oxygen in Use" sign was not posted in appropriate area i.e., near the room door or at the facility entrance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2024
Plan of Correction
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Administrator shall ensure that a No Smoking-Oxygen In Use sign is posted when oxygen tanks are in the facility.
Submit picture proof that the signs are posted.
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillowcases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that none of the resident beds had mattress pads, which poses a potential health and safety risk.
POC Due Date: 05/07/2024
Plan of Correction
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Submit picture proof and a written statement of how the deficiency was corrected.
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: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


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