331880716-10-25-2024-56-AS-MRIO-DADQXB-20241025123316

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880716
Report Date: 10/25/2024
Date Signed: 10/25/2024 12:33:25 PM

Document Has Been Signed on 10/25/2024 12:33 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GRACIOUS CARE INC #2		FACILITY NUMBER:	331880716
ADMINISTRATOR/ DIRECTOR:	NA ZHAO		FACILITY TYPE:	740
ADDRESS:	14598 STONYBROOK CT		TELEPHONE:	(951) 372-0694
CITY:	EASTVALE	STATE: CA	ZIP CODE:	92880
CAPACITY: 6		CENSUS: 5	DATE:	10/25/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Staff - Juan M. Estrada Barajas		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to the facility to verify clearance of Plan of Correction from visit on 10/18/2024. LPA Rico met with staff Juan M. Estrada Barajas and was granted entry to the facility. During today's visit, Licensee Sandy Zhao and House Manager Brandon Marquez as contacted and informed of the visit.

The following deficiencies were not cleared during the time of the visit:

The Licensee was cited on 10/18/2024 for 87208(a) Plan of Operation. During today's visit and based on record review and interview, LPA Rico observed that the Licensee did not have Plan of Operation located in facility file. The Plan of Correction was sending proof to LPA Rico the facility has Plan of Operation maintain in facility file. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days.

The Licensee was cited on 10/18/2024 for 87303(e)(2) Maintenance and Operation. During today’s visit and based on interview and observation. LPA Rico observed that the Licensee did not fix the water temperature. The Plan of Correction was for the licensee to send LPA Rico proof the water temperature has been fixed. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days

The Licensee was cited on 10/18/2024 for 87307(a)(3)(B) Personal Accommodations and Services. During today’s visit, LPA Rico observed bedroom number one had broken dresser. The Plan of Correction was for the Licensee to replace the drawer and send proof to LPA Rico. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACIOUS CARE INC #2	FACILITY NUMBER: 331880716
	VISIT DATE: 10/25/2024

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The Licensee was cited on 10/18/2024 for 87311 Telephones. During today’s visit, LPA Rico verify no staff training was conducted the regulation cited. The Plan of Correction was for the Licensee to send proof that all staff members were train all staff on the regulation 87311 Telephones. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days.

The Licensee was cited on 10/18/2024 for 87412(a)(13)(B)1 Personnel Records. During today’s visit, LPA Rico did not receive copies of Administrator requirements/training's. The Plan of Correction was for the Licensee to send LPA copies of Administrator requirements/training's. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days.

The Licensee was cited on 10/18/2024 for 87219(a) Planned Activities. During today’s visit, LPA Rico verify no staff training was conducted the regulation cited. The Plan of Correction was for the Licensee to send proof all staff members were train on the regulation 87219(a) Planned Activities. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days.

The Licensee was cited on 10/18/2024 for 87555(b)(26) General Food Service Requirements. During today’s visit, LPA Rico did not observe perishable foods for a minimum of two days shall be maintained on the premises. The Plan of Correction was for the Licensee to go grocery shopping and send proof to LPA Rico. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days.

The Licensee was cited on 10/18/2024 for 87457(c) Pre-Admission Appraisal. During today’s visit, based on record review, LPA Rico observed the facility was unable to obtain R1 Pre-admission Appraisal. The Plan of Correction was for the Licensee to send LPA Rico a copy of R1 Pre-admission. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for five (5) days.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACIOUS CARE INC #2	FACILITY NUMBER: 331880716
	VISIT DATE: 10/25/2024

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The Licensee was cited on 10/18/2024 for 87458(a) Medical Assessment. During today’s visit, based on record review, LPA Rico observed the facility was unable to obtain R2 and R3 LIC602. The Plan of Correction was for the Licensee to send LPA Rico a copy of R2 and R3 LIC602. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days.

The Licensee was cited on 10/18/2024 for 87412(g). During today’s visit, based on record review, LPA Rico observed the facility did not have all personnel records at the facility. The Plan of Correction was for the Licensee to send LPA Rico proof all personnel records are maintain at the facility. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days.

The Licensee was cited on 10/18/2024 for 80044(a) Inspection Authority of the Licensing Agency. During today’s visit, LPA Rico was unable to enter the upstairs bedroom. The Plan of Correction was to submit Statement of Understanding to California Code of Regulations (CCR) 8044(a) to LPA Rico and will provide access to Community Care Licensing Department. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days.

Furthermore, a repeated violation of Health and Safety Code Section 1569.618(b). A pervious licensing report was issued on 02/29/2024 giving notice of the same violation. Because you have been cited for repeating the same violation within 12months, the following civil penalty shall be assessed until the violation is corrected. An immediate civil penalty of $250 is hereby assessed for the of 10/25/2024.

An exit interview was conducted with staff Juan M. Estrada Barajas where this report, LIC809 along with Civil Penalty Assessment pages, and Appeal Rights were reviewed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

LIC809 (FAS) - (06/04)

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