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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603683
Report Date: 11/03/2023
Date Signed: 11/03/2023 11:38:59 AM

Document Has Been Signed on 11/03/2023 11:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HOUSE OF GRACE 4 INC.FACILITY NUMBER:
198603683
ADMINISTRATOR:AGUIRRE, MICHELLEFACILITY TYPE:
740
ADDRESS:851 ENTRADA WAYTELEPHONE:
(626) 716-1033
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 0DATE:
11/03/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Licensee Michelle Aguirre, Administrator Barbara SinclairTIME COMPLETED:
11:32 AM
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) Alberto Lopez made an announced visit and was greeted by Licensee/Administrator Michelle Aguirre and Administrator Rebecca Sinclair for the purpose of conducting a pre-licensing and Component 3 visit.

Tour was conducted and the following was observed; medications were in a locked area, physical plant is in good repair, smoke detectors operate properly, fire extinguishers are properly charged, cleaning solutions and sharps are locked, building and grounds are free from hazards, passageways, and doors are not blocked or obstructed, signal system is operable, beds have the required linen/supplies, mattresses and bedsprings are in good repair, resident's rooms have the appropriate furniture (one chair, night stand, adequate lighting for each resident, adequate closet and drawer space), bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture and any assistant devices such as walkers. Water temperature was not within normal range (105 F to 120 F) degrees Fahrenheit. Refrigerator, stove, telephone, sinks, tubs, toilets and showers operate properly. There are enough bath towels, hand towels and wash cloths for all clients. Enough personal hygiene supplies are available for residents.

There are enough linens available to permit weekly changes to ensure use of clean linens at all times by residents. All bathrooms were equipped with grab bars, (one grab bar is loose and needs to be repaired) and non-skid mats. Pantry's cupboards, freezers, stoves, microwaves, refrigerator, and counters are clean. Garbage cans have tight fitting covers. Two day supply of perishables available on day 1 of move in of residents, seven day supply of non-perishable available. The facility has sufficient dining tables and chairs. Pesticides and other toxic substances are stored and locked away from food supply. Resident records are inaccessible to unauthorized persons. Emergency disaster plan, personal rights and complaint procedures are posted with exception of Ombudsman poster.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOUSE OF GRACE 4 INC.
FACILITY NUMBER: 198603683
VISIT DATE: 11/03/2023
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
First Aid Kit is fully stocked. There is adequate seating in common area for licensed capacity. No resident bedrooms are used as public or general passageway to another room, bath or toilet. Night lights are maintained in the hallway and passages to non-private bathrooms. Post labor information as required by law is not posted. Notices of planned activities are posted in a central facility location readily accessible to clients, relatives and representatives of placement and referral agencies. Activity supplies, available. Privacy is provided in all toilets, bath, and shower areas. Facility has a theft and loss policy posted. Emergency exiting plans and telephone numbers are posted. Procedures to file confidential complaints are posted; a copy of resident rights or instructions on how to obtain a copy of the rights is provided to residents. There is a working telephone. Carbon monoxide detector is operable.


The following rooms were inspected: #01, 02, 03, 04.

Physical plant will meet Title 22 Regulations when grab bar in restroom is repaired, ombudsman labor poster is posted, and water temperature is adjusted to be in compliance with department regulations and measure in the range of 105-120 degrees F. Licensee will summit proof of Liability Insurance once obtained.

Exit interview conducted and copies provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5