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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603617
Report Date: 12/04/2025
Date Signed: 12/04/2025 03:15:58 PM

Document Has Been Signed on 12/04/2025 03:15 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 3FACILITY NUMBER:
198603617
ADMINISTRATOR/
DIRECTOR:		AGUIRRE, MICHELLEFACILITY TYPE:
740
ADDRESS:2178 URSINUS CIRCLETELEPHONE:
(626) 716-1033
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 6DATE:
12/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:41 AM
MET WITH:Michelle Aguirre, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual inspection using the Compliance and Regulatory Enforcement (CARE) Tool. Upon arrival, LPA was greeted by Maria Macalino and explained the purpose of the visit. Administrator Michelle Aguirre arrived shortly thereafter.

The facility is licensed to serve residents ages sixty (60) and older, with an approved capacity of six (6) residents, all of whom may be non-ambulatory. The facility is also approved to care for up to six (6) hospice residents. At the time of the inspection, six (6) resident were receiving hospice care.

Facility Tour & Observations

Required postings, including Personal Rights (LIC 613C), Ombudsman information, the Complaint Poster (PUB 475), and the nondiscrimination notice were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms or weapons were present.

Physical Plant

The facility is located in a residential area and is a one-story home consisting of four (4) resident bedrooms, two (2) restrooms one of which is a private restroom along with a living room, kitchen, dining area, laundry room, garage, and front and backyard areas.LPA observed that all four (4) resident bedrooms contained the required furnishings, including a bed, mattress, linens, dresser, chair, and appropriate lighting. Cleaning supplies and toxic substances were inaccessible to residents and locked in hallway closet.Bathrooms were clean and equipped with the required grab bars in the showers and near the toilets, as well as non-skid mats. Hot water temperatures measured 107.6°F in bathroom (1) and 109.2°F in bathroom (2), which are within the required range of 105–120°F.


**Continued on LIC809C**

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2025
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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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)
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Document Has Been Signed on 12/04/2025 03:15 PM - It Cannot Be Edited


Created By: Gabriela Castro On 12/04/2025 at 02:18 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: HOUSE OF GRACE 3
FACILITY NUMBER: 198603617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as two (2) out of three (3) staff files did not contain proof of the required additional 20 hours of annual training, which poses/posed a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/29/2025
Plan of Correction
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The licensee agrees to ensure all staff complete the required 20 hours of annual training. The licensee will submit proof of completed annual training for the two (2) staff identified, along with a training schedule and tracking system to ensure ongoing compliance. Proof of correction will be submitted to the Department by the POC due date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as six (6) out of six (6) resident files did not contain updated re-appraisals, which poses/posed a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/29/2025
Plan of Correction
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The licensee agrees to complete updated re-appraisals for all six (6) residents. The licensee will submit copies of the completed re-appraisals to the Department by the POC due date. In addition, the licensee will implement a tracking system to ensure future re-appraisals are completed and maintained in accordance with regulatory requirements.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2025


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOUSE OF GRACE 3
FACILITY NUMBER: 198603617
VISIT DATE: 12/04/2025
NARRATIVE
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 Extra linens and towels were stored in a hallway cabinet. Smoke and carbon monoxide detectors were tested and found to be functional. Fire extinguishers were observed in the hallway by the garage entrance and inside the garage. No bodies of water were present on the premises. The backyard offered shaded seating. All indoor and outdoor passageways and exits were clear and unobstructed.
Food Service

Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees °F and freezer 0-degree °C) with sufficient supply of 2-day perishable and 7 days non-perishable food. Fresh produce, proteins, and dry goods were stocked. Knives and were observed in a locked kitchen drawer.

Health-Related Services & Records

Six (6) resident files were reviewed and contained current required documents, including Admission Agreements, Pre-Placement Appraisals, Consents, Physician’s Reports with TB results and ambulatory status, and Rights Acknowledgments. Six (6) residents’ medications were reviewed; medications were observed to be centrally stored and kept locked in the hallway closet.

However, based on record review, all six (6) resident files did not contain updated re-appraisals as required by regulation 87463(a).

Disaster Preparedness

Last fire/earthquake drill was conducted on October 5, 2025, with logs available. LIC 610D Emergency Disaster Plan was posted on hallway bulletin board. Emergency supplies (water, food, flashlights, batteries, first aid) were observed in the garage. Infection Control Plan was updated.

Personnel Records & Training

Three (3) staff files were reviewed and included documentation of criminal record clearances, CPR/First Aid certification, and TB screenings. Administrator Certificate for Michelle Aguirre was verified and is valid through August 28, 2026. However, based on record review, staff were missing the required annual training as mandated by regulation.



**Continued on LIC809C**
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOUSE OF GRACE 3
FACILITY NUMBER: 198603617
VISIT DATE: 12/04/2025
NARRATIVE
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Insurance

Liability insurance was in compliance with an expiration date February 21, 2026.

An exit interview was conducted with,Maria Macalino. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. Michelle Aguirre, Administrator was advised of the nature of the deficiencies, the regulatory basis, and the required Plan of Correction (POC). Michelle Aguirre, Administrator agreed to submit proof of correction by the due dates specified. A copy of this report, LIC 809D/809C, and appeal rights will be provided via email.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC809 (FAS) - (06/04)
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