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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603695
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:58:36 PM

Document Has Been Signed on 01/16/2025 02:58 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:GRANT SERENITY ON CHARLOTTE, INC.FACILITY NUMBER:
198603695
ADMINISTRATOR/
DIRECTOR:		KARAPETYAN, ANIFACILITY TYPE:
740
ADDRESS:5588 N.CHARLOTTE AVENUETELEPHONE:
(626) 427-1170
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY: 6CENSUS: 6DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:43 AM
MET WITH:Diana Castellanos, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced annual inspection visit. The purpose of the visit was explained to caregiver Lucila Aguilar. Assistant Administrator Diana Castellanos shortly after. The facility serves elderly residents ages 60 and older. A hospice and Dementia waiver is in place. Facility is a single-story home located in a residential area consisting of six (6) private bedrooms, two (2) bathrooms, kitchen, dining room, living room, laundry area in attached garage with 2 parking spaces, backyard outdoor covered patio, storage shed in the rear of the backyard. Front yard is landscaped with grass and back yard is landscaped with gravel. Twelve (12) CARE tools domains were reviewed.

The following were observed/inspected:



Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs).

Operational Requirements: A Dementia and hospice waiver for 3 residents has been approved. A fire clearance for 6 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 5 or 6. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 7/4/2025

Physical Plant/Environment Safety: 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 are inaccessible to residents. The facility has fully charged fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The last Emergency Disaster drill was conducted on 10/24/24.

Staffing: A total 13 staff members provide care and supervision to the clients.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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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: GRANT SERENITY ON CHARLOTTE, INC.
FACILITY NUMBER: 198603695
VISIT DATE: 01/16/2025
NARRATIVE
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Personnel Records/Staff Training: Administrator certificate expires 6/28/2025. Staff have criminal background clearance and training. Five (5) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training us current.

Resident Records/Incident Reports: A total of six (6) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Medication Administration records are in place. However, documentation errors were observed regarding physician orders. A citation was issued.

RCFE complaint poster and Personal rights were observed posted.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. 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. Residents have modified diets.

Incident Medical and Dental: Three (3) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual.

Residents with Special Health Needs: Three (3) residents are receiving hospice services and two (2) resident receive home health services. Four (4) residents have a Dementia diagnosis. No residents have prohibited health conditions. Full bed rails for mobility assistance were observed in hospice resident's rooms. Resident (R2) had full bed rails without being enrolled in hospice. Staff removed the rails during the visit. A citation was issued.

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



An exit interview was conducted with Assistant Administrator Diana Castellanos. A copy of the report and appeal rights was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/16/2025 02:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 01/16/2025 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: GRANT SERENITY ON CHARLOTTE, INC.
FACILITY NUMBER: 198603695

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)(4)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them.... (4) Knowledge required to safely assist with prescribed medications which are self-administered.
This requirement was not met evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that R3’s MAR had errors, med was Pilocarpine Hydrochloride 1% Ophthalmic Solution was not onsite and staff did not know that hospice discharged the medication on 1/7/24. Additionally, staff are popping meds out of order from bubble pack, which poses a potential health and safety risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Submit proof that all staff were trained in regulation 87411(d)(4), and 87465. It is recommended that Licensee request pharmacy MARs to mitigate MAR errors.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2025 02:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 01/16/2025 at 02:43 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: GRANT SERENITY ON CHARLOTTE, INC.
FACILITY NUMBER: 198603695

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

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 (R2) is not enrolled in hospice and their bed had full bed rails; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Staff removed the rails during the visit. Submit a written plan of correction and If applicable submit a copy of the half-rail physician order and picture evidence by tomorrow.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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