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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603683
Report Date: 11/17/2023
Date Signed: 11/17/2023 01:47:01 PM

Document Has Been Signed on 11/17/2023 01:47 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
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:
11/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:59 AM
MET WITH:Licensee Michelle Aguirre, Administrator Barbara SinclairTIME COMPLETED:
01:56 PM
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Licensing Program Analyst (LPA) Alberto Lopez made a subsequent announced visit and was greeted by Licensee/Administrator Michelle Aguirre. LPA explained the purpose of the visit.

The purpose of the visit is to verify Licensee compliance for the following:

1) Ombudsman poster
2) Labor law poster
3) Water temperature compliance.
4) Grab bar repair.

LPA verified that Licensee corrected the following:

1) Ombudsman poster witnessed by LPA during visit.
3) Water temperature compliance. Verified that water temperature range measured between 108.0 and 116.2 degrees F which is within range of 105.0 - 120 degrees F.
4) Grab bar repair. LPA verified repair of grab bar.

The Labor law poster (2) was not posted at facility and Licensee stated that it is not required.

LPA is referring the application back to CAB to make the decision if labor law poster is required and approve Licensee.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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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