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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880740
Report Date: 12/11/2024
Date Signed: 12/11/2024 02:18:50 PM

Document Has Been Signed on 12/11/2024 02:18 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 HOMEFACILITY NUMBER:
331880740
ADMINISTRATOR/
DIRECTOR:		BRANDON MARQUEZ GUTIERREZFACILITY TYPE:
740
ADDRESS:12515 HUDSON RIVER DRIVETELEPHONE:
(951) 444-6651
CITY:EASTVALESTATE: CAZIP CODE:
91752
CAPACITY: 6CENSUS: 3DATE:
12/11/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Staff- Martiza A MendozaTIME VISIT/
INSPECTION COMPLETED:
02:30 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 12/15/2024. LPA Rico met with caregiver Martiza A Mendoza and was granted entry to the facility. During today's visit, Administrator Brandon Marquez was contacted and informed of the visit.

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

The Licensee was cited on 12/5/2024 for 87355 Criminal Record Clearance (e). During today's visit, based on record review, observation and interview, LPA Rico observed that the Licensee did not have an updated LIC500. The Plan of Correction was to send LPA Rico proof of facility LIC500. 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 five (5) days.

An exit interview was conducted and this report, LIC809 along with Civil Penalty Assessment pages, and Appeal Rights were reviewed and provided to caregiver Martiza A Mendoza.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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