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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880716
Report Date: 06/17/2025
Date Signed: 06/17/2025 02:14:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/31/2022 and conducted by Evaluator Raquel Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221031141433
FACILITY NAME:GRACIOUS CARE INC #2FACILITY NUMBER:
331880716
ADMINISTRATOR:NA ZHAOFACILITY TYPE:
740
ADDRESS:14598 STONYBROOK CTTELEPHONE:
(951) 372-0694
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 2DATE:
06/17/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Staff Ricardo Rojas GarciaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Licensee failed to immediately notify responsible party of resident death.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Staff Ricardo Rojas Garcia and explained the purpose of the visit. The investigation consisted of staff and resident interviews along with obtaining documentation pertaining to allegation.

For the allegation, Licensee failed to immediately notify responsible party of resident death.

Based on interviews, LPA Hernandez observed no copy of death report was provided to former Resident #1 (R1) responsible party. In addition, based on record review, LPA Hernandez observed facility did not provide death report of R1 to Community Care Licensing.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 56-AS-20221031141433
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GRACIOUS CARE INC #2
FACILITY NUMBER: 331880716
VISIT DATE: 06/17/2025
NARRATIVE
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Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met.

An exit interview was conducted and the forms LIC9099 and LIC9099D were discussed and left with Ricardo Rojas Garcia along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/31/2022 and conducted by Evaluator Raquel Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221031141433

FACILITY NAME:GRACIOUS CARE INC #2FACILITY NUMBER:
331880716
ADMINISTRATOR:NA ZHAOFACILITY TYPE:
740
ADDRESS:14598 STONYBROOK CTTELEPHONE:
(951) 372-0694
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: DATE:
06/17/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Staff Ricardo Rojas GarciaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Licensee has failed to provide a refund upon residents death.
Caregiver unable to communicate with residents family.
Licensee failed to provide an admission agreement within 7 days.
Licensee altered the admission agreement after responsible party signed the agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Staff Ricardo Rojas Garcia and explained the purpose of the visit. The investigation consisted of staff and resident interviews along with obtaining documentation pertaining to allegation.

For the allegation, Licensee has failed to provide a refund upon residents death.

LPA Hernandez spoke with Administrator Sandy Zhao where it was stated former Resident #1 (R1) responsible party was provided with a refund upon R1's death. Administrator Sandy Zhao provided LPA Hernandez with copy of bank statement indicating refund was processed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20221031141433
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GRACIOUS CARE INC #2
FACILITY NUMBER: 331880716
VISIT DATE: 06/17/2025
NARRATIVE
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For the allegation, Caregiver unable to communicate with residents family.

LPA Hernandez observed facility staff able to communicate with residents in care. Additionally, it was indicated by Staff #2 (S2) that facility staff have no issues communicating with resident's families.

For the allegation, Licensee failed to provide an admission agreement within 7 days.

LPA Hernandez spoke with Administrator Sandy Zhao where it was stated responsible party was provided with an admission agreement copy. Administrator stated responsible party did sign admission agreement within seven days following resident's admission. LPA Hernandez observed signature from R1's responsible party. Based on record review, there was not enough evidence to corroborate admission agreement was not provided.

For the allegation, Licensee altered the admission agreement after responsible party signed the agreement.

LPA Hernandez observed admission agreement for R1 where signatures from R1's responsible party were obtained. Administrator Sandy Zhao stated admission agreement has remained the same. Based on record review, there was not enough evidence to corroborate admission agreement was altered.

Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and this form LIC9099-A was discussed and left with Staff Ricardo Rojas Garcia

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 56-AS-20221031141433
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACIOUS CARE INC #2
FACILITY NUMBER: 331880716
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2025
Section Cited
CCR
87211(1)(A)
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87211 Reporting Requirements (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... (A) Death of any resident from any cause.
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Licensee stated to notify all resident's responsible parties as well as licensing department for future deaths and severe occurences.
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Based on record review, licensee did not comply with section cited above by not ensuring death report of former Resident #1 (R1) was provided to R1's responsible party, which poses an immediate health, safety, and personal rights risk to those in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5