<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800447
Report Date: 03/23/2022
Date Signed: 03/23/2022 01:32:18 PM

Document Has Been Signed on 03/23/2022 01:32 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:GRATEFUL HEART HOME CARE INCFACILITY NUMBER:
331800447
ADMINISTRATOR:UY, CHARMAINEFACILITY TYPE:
740
ADDRESS:14223 POINTER LOOPTELEPHONE:
(951) 427-1800
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 4DATE:
03/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rholette Miller, CaregiverTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Amy Goldenberg and Rayshaun Nickolas made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPAs were met at the door by facility staff and granted entry into the home. Staff are wearing masks. LPA is informed that there are no COVID positive individuals in the home. The facility has an approved mitigation plan on file with this agency. Precautionary Covid-19 postings are present at the front door and at the entry point. There is one entry point designated where sign in procedures and screening will occur. The staff are screening visitors upon entry into the facility.

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and has a limited supply of Personal Protective Equipment (PPE). LPA discussed the availability of additional PPE supplies to the facility at the time of this visit and advised the facility representatives to contact our office in the event additional supplies are necessary. LPAs review of criminal record clearance revealed that S1 and S2 have criminal record clearance, however, those clearances have not been associated to this facility number. LPAs tour of the facility revealed that the garage had a room with lock portioned off . This part of the facility was inaccessible to LPAs during this visit.

Based on observations made during today’s inspection, the following deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations. See LIC 809D. LPAs reviewed this report with and a copy was provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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 3
Document Has Been Signed on 03/23/2022 01:32 PM - It Cannot Be Edited


Created By: Amy Goldenberg On 03/23/2022 at 11:11 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GRATEFUL HEART HOME CARE INC
FACILITY NUMBER: 331800447

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
873550
(e) All individuals subject to a criminal record review pursuant to HEalth and Safety Code 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearanceas specified in 87335 (c).

This requirement is not met as evidenced by: Review of criminal record clearance shows that S1 and S2 clearances are not associated with this facility.
Deficient Practice Statement
1
2
3
4
Based on review of associated criminal record clearancese licensee did not comply with the section cited above in 2 out of 2 staff working on this day do not have a criminal record clearance associated to this facility number. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2022
Plan of Correction
1
2
3
4
Licensee to transfer criminal record clearance for S1 and S2 to this facility number by POC due date and submit a statement of understanding of the regulation section cited.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Nedra Brown
LICENSING EVALUATOR NAME:Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/23/2022 01:32 PM - It Cannot Be Edited


Created By: Amy Goldenberg On 03/23/2022 at 11:46 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GRATEFUL HEART HOME CARE INC
FACILITY NUMBER: 331800447

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87755

(a) Any duly authorized officer, employee, agent of the licensing agency may , upon proper identification and upon stating purpose of his/her visit, enter and inspect the entire premis of any place providing services at any time, with or without advanced notice.
This requirement is not met as evidenced by: LPA is unable to acces a locked space in the facility during this visit to verify content.
Deficient Practice Statement
1
2
3
4
Based on LPA tour of the facility, the licensee did not comply with the section cited above. LPA Is unable to access a portioned off locked space of the garage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2022
Plan of Correction
1
2
3
4
Licensee to provide access to the locked space in the facility by POC due date along with submission of a statement of understanding of section cited by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Nedra Brown
LICENSING EVALUATOR NAME:Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3