331880740-10-25-2024-56-AS-MRIO-DADTQW-20241025145638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880740
Report Date: 10/25/2024
Date Signed: 10/25/2024 02:56:55 PM

Document Has Been Signed on 10/25/2024 02:56 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 HOME		FACILITY NUMBER:	331880740
ADMINISTRATOR/ DIRECTOR:	BRANDON MARQUEZ GUTIERREZ		FACILITY TYPE:	740
ADDRESS:	12515 HUDSON RIVER DRIVE		TELEPHONE:	(951) 444-6651
CITY:	EASTVALE	STATE: CA	ZIP CODE:	91752
CAPACITY: 6		CENSUS: 3	DATE:	10/25/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:57 PM
MET WITH:	Staff- Osvaldo Nunes Aldrete		TIME VISIT/ INSPECTION COMPLETED:	03:15 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 10/16/2024. LPA Rico met with staff Osvaldo Nunes Aldrete and was granted entry to the facility. During today's visit, Licensee Sandy Zhao and House Manager Brandon Marquez were contacted and informed of the visit.

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

The Licensee was cited on 10/16/2024 for 1569.618(b) Other Provisions. During today's visit and based on record review, observation and interview, LPA Rico observed that the Licensee did not have a designated substitute present and the Administrator present. The Plan of Correction was to send LPA Rico proof of their designated substitutes along with their work schedule. 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 eight (8) days.

The Licensee was cited on 10/16/2024 for 87303(a)Maintenance and Operation. During today's visit, LPA Rico observed kitchen cabins to be dirty. The Plan of Correction was for Licensee to clean kitchen cabins and send proof to LPA Rico. 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 eight (8) days.

The Licensee was cited on 10/16/2024 for 87303(d)Maintenance and Operation. During today's visit, LPA Rico observed the Licensee did not fix the hallway lights. The Plan of Correction was for Licensee to send proof the hallway lights have 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 eight (8) 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 HOME	FACILITY NUMBER: 331880740
	VISIT DATE: 10/25/2024

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The Licensee was cited on 10/16/2024 for 87303(e)(3) Maintenance and Operation During today's visit based on record review, observation and interview, LPA Rico observed the Licensee did not have warning signs for hot water. The Plan of Correction was to send LPA proof the Licensee has posted warning signs on resident's bathrooms. 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 eight (8) days.

The Licensee was cited on 10/16/2024 for 1569.618(c) Other Provisions. During today's visit based on record review, observation and interview, LPA Rico observed the Licensee did not update the LIC500. The Plan of Correction was to send LPA a copy of the updated LIC500. enroll S1 to a CPR class and will send proof to LPA. Licensee also stated they will send a copy of all staff CPR. 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 eight (8) days.

The Licensee was cited on 10/16/2024 for 1569.618(c)(3) Other Provisions. During today's visit based on record review, LPA Rico observed S1 was the only staff present and did not have a CPR card. The Plan of Correction was for enroll S1 to a CPR class and will send proof to LPA. Licensee also stated they will send a copy of all staff CPR. 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 eight (8) days.

The Licensee was cited on 10/16/2024 for 87355(e)(3) Criminal Record Clearance. During today's visit based on record review, LPA Rico review the facility did not transfer S1 criminal clearance to be associated to the facility. The Plan of Correction was to send LPA Rico proof S1 criminal clearance is associated to the facility. 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 eight (8) days.

The Licensee was cited on 10/16/2024 for 87465(d)(3) Incidental Medical and Dental Care Services. During today's visit based on record review and interviews. LPA verify no staff training was conducted. The Plan of Correction was for the Licensee to train all staff on the regulation cited and send proof to LPA.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 eight (8) days.

The Licensee was cited on 10/16/2024 for 87465(e)Incidental Medical and Dental Care Services. During today's visit LPA verify R1 medications were not listed on file. The Plan of Correction was for the Licensee to have R1 medications listed on 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 eight (8) 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 HOME	FACILITY NUMBER: 331880740
	VISIT DATE: 10/25/2024

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The Licensee was cited on 10/16/2024 for 87705(c)(5)Care of Persons with Dementia. During today's visit, LPA Rico observed R2 did not have their medical assessment and no appointment was schedule. The Plan of Correction was for Licensee to send proof to LPA Rico the Licensee had schedule a medical assessment for R2. 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 eight (8) days.

The Licensee was cited on 10/16/2024 for 87705(j) Care of Persons with Dementia. During today's visit based on record review,and interviews LPA Rico verify no staff training were conducted. The Plan of Correction was for the Licensee to send proof to LPA they train their staff on the regulation cited. 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 eight (8) days.

The Licensee was cited on 10/16/2024 for 87208(a)Plan of Operation. During today's visit, based on record review LPA did not observed the Plan of Operation in facility file. The Plan of Correction was to send LPA proof where the plan of operation will be located at the facility. 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 10/16/2024 for 87303(c) Maintenance and Operation. During today's visit, based on observation LPA verify the window screen has not been replaced. The Plan of Correction was to replaced the window screen. 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 10/16/2024 for 87311 Telephones. During today's visit, LPA Rico tested facility phone. The facility phone is still out of service. The Plan of Correction was to fix facility and send proof to LPA Rico. 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 10/16/2024 for 1569.618(c)(4)Other Provisions. During today's visit, LPA Rico observed the electric wires in the hallway have not been fixed. The Plan of Correction was to fix the wires and send proof to LPA Rico. 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.

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 HOME	FACILITY NUMBER: 331880740
	VISIT DATE: 10/25/2024

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The Licensee was cited on 10/16/2024 for 87219(a)Planned Activities. During today's visit, LPA observed the facility did not have activities calendar. The Plan of Correction was send to send LPA Rico a copy of activities calendar and train their staff on the regulation cited. 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 10/16/2024 for 87465(a)(8)Incidental Medical and Dental Care Services. During today's visit, LPA Rico observed the facility did not a completed first aid kit. The Plan of Correction was to send proof the facility first aid kit had all the supplies contain. 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

An exit interview was conducted with staff Staff- Osvaldo Nunes Aldrete 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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