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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880740
Report Date: 03/21/2025
Date Signed: 03/27/2025 01:43:17 PM

Document Has Been Signed on 03/27/2025 01:43 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:
03/21/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Caregivers Carmen Guadalupe Rodriguez Olague
and Osvaldo Nunes Aldrete 		TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to conduct a Health and Safety check of the residents in care at the facility. LPA Rico met with caregiver Carmen Guadalupe Rodriguez Olague and explained the reason of the visit. Licensee Sandy Zao was contacted along with Administrator Brandon Marquez. Both indicated they were unavailable to be at the facility.

During facility tour, LPA Rico observed the facility did not have an Administrator or designated substitute on facility premises. In addition, S1 and S2 stated they are not the manager nor Administrator. 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.

Furthermore, LPA Rico observed the facility did not have one (1) out of the three (3) residents Physician Report LIC602A. During medication audit, LPA Rico observed the facility did not document R2 PRN response/result.

Based on the observations made during today’s visit, three (3) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) (809D) (LIC421FC7/17) was discussed and provided to caregiver Osvaldo Nunes Aldrete. Along with a copy of appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Mary Rico
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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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Document Has Been Signed on 03/27/2025 01:43 PM - It Cannot Be Edited


Created By: Mary Rico On 03/21/2025 at 12:46 PM
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: 03/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2025
Section Cited
CCR
87458(a)

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87458(a) Medical Assessment
Prior to a person's acceptance.. the licensee shall obtain and keep on file.signed by a physician, made within the last year. Physician's Report, to obtain the medical assessment.This requirement is not met as evidenced by:
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Licensee stated they will obtain a copy of R1 LIC602 and will also send a copy to LPA Rico.
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Based on record review, the licensee did not comply with the section cited above by not having a R1 LIC602 which poses/posed a potential health, safety or personal rights risk to persons in care.
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POC due date 3/23/2025

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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: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/27/2025 01:43 PM - It Cannot Be Edited


Created By: Mary Rico On 03/21/2025 at 01:26 PM
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: 03/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2025
Section Cited
CCR
87465(c)(3)

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Incidental Medical and Dental Care Services 87465(c)(3)A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
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The Licensee stated she will train all caregivers on the regulation cited above and will send LPA a copy to LPA Rico.
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Based on medication audit 1 out of the 3 residents did not have their PRN documented properly. The licensee did not comply with the section cited above which poses an immediate health, safety, or personal rights risk to persons in care.
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POC due date 3/24/2025

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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: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


LIC809 (FAS) - (06/04)
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