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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006444
Report Date: 01/21/2026
Date Signed: 01/21/2026 12:07:04 PM

Document Has Been Signed on 01/21/2026 12:07 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: 3DATE:
01/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:29 AM
MET WITH:Donia Anaim-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:21 PM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced visit for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by Administrator (AD) Donia Anaim. LPA observed that AD Donia Anaim has a valid AD 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 bedroom, a living room, a family room, a kitchen, a dining room, and an detached two car garage. LPA and AD tour the interior and exterior of the facility. On today's visit, LPA observed three residents in care, one of which is on hospice. LPA observed residents relaxing in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall in the entryway of the facility. LPA toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. 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. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Hot water temperature measured between 113.3 and 116.1 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies.

CONTINUED ON LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Alvaro Ramirez Jr.
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 01/21/2026
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Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers was charged and located by the living room.

LPA observed the emergency disaster and evacuation plan which is located by the entrance. Facility had back-up emergency food and water supply.

LPA observed that the First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care. Medications are locked in a cabinet in the kitchen.

For the exterior portion, LPA observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard. LPA did not observed a body of water.

LPA reviewed three resident files and two staff files. LPA interviewed residents and staff present.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPA advised AD to use the general email address:


CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

An exit interview was conducted with AD Anaim.

A copy of this report was provided at the time of exit.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Alvaro Ramirez Jr.
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
LIC809 (FAS) - (06/04)
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