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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 02:19:45 PM

Document Has Been Signed on 12/11/2024 02:19 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:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Staff- Martiza A MendozaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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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 completed a case management visit to cite for deficiencies found during the facility visit. During today's visit, Administrator Brandon Marquez was contacted and informed of the visit.

During record review, LPA observed R1 and R2 records were missing. S1 informed LPA that R2 is a new resident and official move in date was 11/28/2024. S1 admitted the facility did not have R1 and R2 record file at the facility. S1 also stated that the facility no longer has R2 file at the facility, and no copies to provide LPA.

Furthermore, based on interview and observed the facility did not have an Administrator or designated substitute on facility premises. A previous licensing report was issued on 10/16/2024 giving notice of the same violation. Because the licensee has been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed until the violation is corrected.

In addition, LPA observed S1 did not have a CPR certificate and was the only staff on premises. A previous licensing report was issued on 10/16/2024 giving notice of the same violation. Because the licensee has been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed until the violation is corrected.

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)
Page: 1 of 3
Document Has Been Signed on 12/11/2024 02:19 PM - It Cannot Be Edited


Created By: Mary Rico On 12/11/2024 at 10:05 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
RIVERSIDE, CA 92507

FACILITY NAME: GRACIOUS CARE HOME
FACILITY NUMBER: 331880740

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2024
Section Cited
CCR
1569.618(b)

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(b) At least one administrator, facility manager, or designated substitute who is at least .. Title 22 ... the premises 24 hours per day... The designated substitute shall meet qualifications that include, but are not limited to, all of the following...
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Administrator stated they will send a copy of their designated substitutes along with their work schedule. Administrator also stated the Licensee will ensure the facility has a designated present on premises 24hours.
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Based on observation and interview , the licensee did not comply with the section cited above by not having a designated substitiute that meets qualifications present which poses an immediate health, safety or personal rights risk to persons in care.
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POC due date 12/12/2024
Type A
12/12/2024
Section Cited
CCR87509(d)

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87509(d)Resident Records
(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:
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Administrator stated they will send LPA Rico R2 records.
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Based on observation and interview , the licensee did not comply with the section cited above by not having a R1 and R2 records at the facility an immediate health, safety or personal rights risk to persons in care.
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POC due date 12/12/2024
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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/11/2024 02:19 PM - It Cannot Be Edited


Created By: Mary Rico On 12/11/2024 at 11:30 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
RIVERSIDE, CA 92507

FACILITY NAME: GRACIOUS CARE HOME
FACILITY NUMBER: 331880740

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2024
Section Cited
HSC
1569.618(c)(3)

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1569.618(c)(3) Administration.. qualifications; (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This requirement is not met as evidenced by:
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Administrator stated they will enroll S1 to a CPR class and will send proof to LPA. Licensee also stated they will send a copy of all staff CPR.
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Based on record review, the licensee did not comply with the section cited above, S1 did not have a CPR card which poses an immediate health, safety or personal rights risk to persons in care.
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POC due date 12/12/2024

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


LIC809 (FAS) - (06/04)
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