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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006444
Report Date: 01/29/2025
Date Signed: 01/29/2025 04:24:41 PM

Document Has Been Signed on 01/29/2025 04:24 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GRACEFUL LIVING ADULT HOMEFACILITY NUMBER:
306006444
ADMINISTRATOR/
DIRECTOR:		GARCIA, MARIAFACILITY TYPE:
740
ADDRESS:487 S DUNAS STTELEPHONE:
(562) 688-8895
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: 5DATE:
01/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Administrator Donia AnaimTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by caregiver staff after explaining the purpose for the visit. Administrator Donia Anaim was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Donia Anaim has a valid Administrator certificate which expires on October 7, 2026.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, with a hospice waiver for six. The facility is a single story home with five private resident bedrooms, two shared resident bathrooms, one staff room, a living room, a family room, a kitchen, a dining room, an unattached two car garage, and a shed located in the backyard. LPA accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed five residents in care, five of which are on hospice, and two caregiver staff present. LPA observed residents relaxing in their respective bedrooms and in the family room. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall in the entryway of the facility. LPA inspected all five resident bedrooms and they were observed to be free of hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident linens and blankets to be clean. LPA observed additional linens stored in a closet in the resident hallway. LPA observed Oxygen in Use signs posted in the appropriate resident doorways. LPA observed that the staff room is kept locked and inaccessible to residents in care. LPA inspected the two shared resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floors. Faucets and toilets were operational. Hot water temperature measured between 117.5 and 117.6 degrees Fahrenheit.

LPA observed the kitchen has a two day perishable and seven day non-perishable food supply on hand. LPA observed kitchen appliances to be clean and operational. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACEFUL LIVING ADULT HOME
FACILITY NUMBER: 306006444
VISIT DATE: 01/29/2025
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The four burner gas stove lights unassisted. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. A fire extinguisher is located in the family room and it was observed to be charged and serviced as of December 12, 2024. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on December 5, 2024. The centrally stored medication is stored in a locked cabinet in the kitchen. LPA observed a First Aid Kit to be stored in the locked kitchen cabinet. LPA inspected the First Aid Kit and observed it to have all the required components.

LPA accompanied by the AD toured the exterior portion of the facility. LPA observed the exterior portion to be free of obstructions and hazards. LPA observed an shaded outdoor seating area with furniture for resident use. The door leading to the unattached two car garage is kept locked and inaccessible to residents in care. LPA observed the facility has a three day emergency food and water supply stored in the two car garage. LPA inspected the shed located in the backyard. LPA observed the shed to be locked and inaccessible to residents in care. LPA observed the shed to be used for storage. The two perimeter gate on the north side of the facility are self-latching and can be opened in an evacuation. There are no bodies of water located on the premises.

LPA reviewed all five resident files. LPA observed that Resident #1, Resident #2, Resident #3, and Resident #4 had Reappraisals that were outdated. LPA also observed that Resident #1, Resident #2, Resident #3, and Resident #4 did not have a valid Admission Agreement on file. LPA reviewed all five residents' medication and medication records. LPA reviewed two staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Donia Anaim. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2025 04:24 PM - It Cannot Be Edited


Created By: Brandon Lopez On 01/29/2025 at 04:04 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACEFUL LIVING ADULT HOME
FACILITY NUMBER: 306006444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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4
Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Based on file review, LPA observed that Resident #1, Resident #2, Resident #3, and Resident #4 had Reappraisals that were outdated.
POC Due Date: 02/12/2025
Plan of Correction
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AD agreed to submit an updated Reappraisal for Resident #1, Resident #2, Resident #3, and Resident #4 to LPA via email or fax by POC date.
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

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 in which poses/posed a potential health, safety or personal rights risk to persons in care. Based on file review, LPA observed that Resident #1, Resident #2, Resident #3, and Resident #4 do not have a valid Admission Agreement on file. The Admission Agreements on file are from the previous licensed facility with the previous facility number.
POC Due Date: 02/12/2025
Plan of Correction
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AD agreed to submit a valid Admission Agreement for Resident #1, Resident #2, Resident #3, and Resident #4 to LPA via email or fax by POC date.
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:Sheila Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
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