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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006542
Report Date: 10/09/2025
Date Signed: 10/09/2025 12:11:35 PM

Document Has Been Signed on 10/09/2025 12:11 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: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: 5DATE:
10/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator Glenn NavarroTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On October 9, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Administrator (AD) Glenn Navarro was notified via telephone and later arrived to assist with the inspection. LPA observed that Glenn Navarro has a valid Administrator certificate which expires on July 22, 2026.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for six. The facility is a single story home with six private resident bedrooms, two staff bedroom, four resident bathrooms, a living room, a dining room, a kitchen, and an attached two car garage. LPA, accompanied by the AD, conducted a tour of the interior portions of the facility. On today's visit, LPA observed five resident in care and two care giving staff present. LPA observed residents relaxing in their respective bedrooms. LPA observed the See Something, Say Something poster, (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected all six resident bedrooms and observed them to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed additional linens to be stored in a hallway closet. LPA inspected the four resident bathrooms and observed them to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 103.1 to 111 degrees Fahrenheit. LPA observed the two staff bedrooms are kept locked and inaccessible to residents in care.

LPA observed the kitchen has a two day perishable and a seven day non-perishable food supply on hand. LPA observed kitchen appliances to be clean and operational. CONTINUED ON LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2025
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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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: GRACE SENIOR SOLUTIONS #1
FACILITY NUMBER: 306006542
VISIT DATE: 10/09/2025
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LPA observed the five 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 separate locked kitchen cabinet under the sink. LPA observed a fire extinguishers to be mounted on the wall by the entryway of the facility and it was observed to be charged and serviced as of July 14, 2025. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on July 18, 2025.

LPA observed the centrally stored medication to be kept in a locked closet by the living room. LPA observed the facility has a First Aid Kit stored in the closet and it had all the required components. LPA observed the door leading to the attached two car garage to be kept locked and inaccessible to residents in care. LPA observed the two car garage to be used for storage and laundry. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA, accompanied by the AD, conducted a tour of the exterior portion of the facility. The exterior portion was observed to be free of hazards and obstructions. LPA observed a shaded outdoor seating area with furniture for resident use. LPA observed the perimeter gate of the facility to be self latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all five resident files. LPA observed that Resident #1 (R1) is diabetic and requires insulin injections. Staff interviews confirmed that facility staff are providing the injections to R1 and not a licensed medical professional. LPA reviewed the residents' medication and medication records. LPA observed the facility was providing one unprescribed supplement to Resident #3 (R3) and ten unprescribed supplements/medications to Resident #5 (R5) without valid prescriptions. LPA reviewed four 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 on the attached LIC809-D. An exit interview was conducted with Administrator Glenn Navarro. A copy of the report and Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/09/2025 12:11 PM - It Cannot Be Edited


Created By: Brandon Lopez On 10/09/2025 at 11:50 AM
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: GRACE SENIOR SOLUTIONS #1
FACILITY NUMBER: 306006542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. LPA observed the facility was providing one unpresribed supplement to Resident #3 (R3) and ten unprescribed supplements/medications to Resident #5 (R5) and without valid prescriptions.
POC Due Date: 10/10/2025
Plan of Correction
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The Administrator agreed to stop providing all unprescribed supplement/medications immediately. The Administrator stated that they will provide an in service training with all staff regarding medication and providing the correct medications to residents. The Administrator agreed to provide the training to LPA via email or fax by POC date.
Type A
Section Cited
CCR
87465(a)(5)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During file review, LPA observed that Resident #1 (R1) is diabetic and requires insulin injections. Staff interviews confirmed that facility staff are providing the injections to R1 and not a licensed medical professional. Per R1's LIC602, R1 is not able to administer her own injections.
POC Due Date: 10/09/2025
Plan of Correction
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The Administrator stated that they will contact R1's Primary Care Physician to reevaluate R1 to see if she will be able to administer her own injection. The Administrator stated that they will create a written plan on how they will address R1's care plan moving forward. The Administrator agreed to provide LPA the written plan 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
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