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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006542
Report Date: 10/01/2024
Date Signed: 10/01/2024 10:52:42 AM

Document Has Been Signed on 10/01/2024 10:52 AM - 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:GRACE SENIOR SOLUTIONS #1FACILITY NUMBER:
306006542
ADMINISTRATOR/
DIRECTOR:		GHAHYASI, JENNIFERFACILITY TYPE:
740
ADDRESS:2431 E ORANGEVIEWTELEPHONE:
(714) 396-4321
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 6CENSUS: 6DATE:
10/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Jennifer GhahyasiTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analysts (LPA) Jerome Haley made an announced visit for the purpose of conducting a pre-licensing evaluation. LPA Haley was greeted and granted entry by applicant Jennifer Ghahyasi.

Initial application: To operate a Residential Care Facility for the Elderly, with a capacity of 6 non-ambulatory residents was submitted to the department for licensure.



Fire clearance: Orange County Fire Authority granted the Fire Clearance May 16, 2024

Structure:
The facility is a single level structure, with an attached garage. There’s a total of 8 bedrooms, 6 of which are used for residents and 2 bedrooms are designated for staff. There’s one living room space, two dining areas, and four bathrooms. Bedrooms (Residents): All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Grab bars are tightly secured. Hot Water temperature measured in the range of 105.6 and 115.8 degrees Fahrenheit. Kitchen: 3 of 4 burners were operational on the gas stove. Sharps are locked in a drawer. Food Service: A food supply that meets regulation requirements was observed in the refrigerator. A non-perishable food supply that meets regulation requirements was observed, A sample menu was observed on the refrigerator. Office Area: There's no designated office area. Staff members use the smaller dining room space to work and there’s a fax machine/copy machine in the garage. Laundry: There's a laundry area in the garage with a washer and dryer. Toxins: All toxic chemicals and cleaning solutions are inaccessible to residents and are stored in a locked cabinet in the garage. Resident & Staff Files: Resident and staff files are stored in a locked cabinet under the fax machine/copier in the locked garage.

Medications/First-Aid Kit: Medications are kept in a locked medication cart that’s stored in the smaller dining room space where the staff members get their work done. A first aid kit with all the required elements is mounted on the wall at the entrance of the facility.
Continued on LIC809C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: GRACE SENIOR SOLUTIONS #1
FACILITY NUMBER: 306006542
VISIT DATE: 10/01/2024
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Linens & Hygiene Supplies: Adequate supply of linen was stored in cabinets in the hallway. An additional supply of hygiene items are stored in the garage.

Backyard/Exterior:
There’s a large backyard with self-latching exit gate. A shaded patio area with a table and chairs was observed. All walkways were clear and free of obstruction.

Bodies of Water: No bodies of water were observed.

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational. A carbon monoxide detector was observed mounted on the wall in between the kitchen and large dining room.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan, a list of emergency phone numbers, house rules on the facility postings board in the living room area, and a sample menu posted in the kitchen.

Fire Extinguisher: Observed full charged mounted on the wall as soon as you enter the facility next to the front door.

Component III: Is not ready to be presented at this time. Component III will be presented after corrections are made and the follow up visit is completed.

Corrections: The applicant has two corrections to make before the facility is ready to be licensed.
1) Repair or replace the stove. The front right burner on the stove is not working. The stove should light unassisted.
2) Discard the bulk items on the side of the facility.

A follow up visit is tentatively scheduled for Thursday, October 3, 2024 around 1:00pm.
An exit interview was conducted, and a copy of this report was provided to applicant Jennifer Ghayasi.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
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