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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603683
Report Date: 09/17/2024
Date Signed: 09/17/2024 05:10:22 PM

Document Has Been Signed on 09/17/2024 05:10 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/
DIRECTOR:		AGUIRRE, MICHELLEFACILITY TYPE:
740
ADDRESS:851 ENTRADA WAYTELEPHONE:
(626) 716-1033
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 6DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Mark Alvin Arbis, Staff TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted an annual inspection on 9/17/24. LPA arrived unannounced and met with Staff, Alvin Arbis. The purpose for the visit was explained. Administrator, Michelle Aguirre, arrived shortly after to assist with the visit. The facility is licensed for 6 non-ambulatory residents, ages 60 and over. There is a hospice waiver for 4 residents.

LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tools.
The facility consists of 3 resident shared bedrooms, 1 staff room, 2 1/2 bathrooms, living room, dining room, kitchen, laundry area, and detached garage. There are no swimming pool or bodies of water on the premises. The bedrooms have the required furniture, storage space, and sufficient lighting. The spacious backyard has a shaded area for residents. There is an operable carbon monoxide detector and smoke detectors throughout the home.
Knives and cleaning supplies are locked. There is sufficient space to accommodate indoor and outdoor activities. Facility has 2 day perishable and at least a week of non-perishable food.
There are currently 6 residents residing at the facility. LPA reviewed all the residents files and the required documents are maintained in their files. Medications are centrally stored and inaccessible to residents. There were no discrepancies found for the meds. The personal rights, complaint and ombudsman posters are posted in a prominent area. LPA reviewed 3 staff files. The administrator's (Michelle Aguirre) certificate expired on 8/28/24. Per the Administrator, she is still in the process of completing the courses to renew the certificate. Staff have current CPR & First Aid certificates. LPA provided technical advisories on annual training for staff. Facility has the Emergency Disaster Plan posted. LPA issued a technical advisory on emergency drills in order to satisfy the requirement.

A deficiency was issued today. An exit interview was held and a copy of this report and technical advisory notes were given to the staff.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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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Document Has Been Signed on 09/17/2024 05:10 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 09/17/2024 at 03:07 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 4 INC.
FACILITY NUMBER: 198603683

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405 Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in which the administrator has a expired administrator's certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2024
Plan of Correction
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The licensee shall submit proof of renewal documents submitted to the Administrator Certification Bureau by POC due date 10/8/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
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