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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880740
Report Date: 06/20/2025
Date Signed: 06/20/2025 02:22:51 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
12/04/2024 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241204090408
FACILITY NAME:GRACIOUS CARE HOMEFACILITY NUMBER:
331880740
ADMINISTRATOR:BRANDON MARQUEZ GUTIERREZFACILITY TYPE:
740
ADDRESS:12515 HUDSON RIVER DRIVETELEPHONE:
(951) 444-6651
CITY:EASTVALESTATE: CAZIP CODE:
91752
CAPACITY:6CENSUS: 2DATE:
06/20/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator - Brandon MarquezTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Due to lack of care and supervision resident sustained a pressure injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Rico conducted unannounced visit to deliver findings for the allegations listed above. LPA met with Administrator Brandon Marquezand explained the purpose of the visit. The investigation conducted by Department staff consisted of staff, resident interviews and review of pertinent records.

Allegation, Resident developed a pressure injury due to staff neglect.

Evidence shows that R1 sustained a Stage 4 pressure injury on sacrum. However, the wound developed prior to R1 moving into the facility. Evidence show that R1 sustained a Stage 4 pressure injury on Sacrum prior to being placed at Gracious Care Home. Evidence shows that R1was receiving wound care services from Home Health. In addition, Licensed Vocational Nurse (LVN) confirmed they would visit R1 and provided wound care along with catheter care. During staff interviews 2 out of the 3 staff stated R1 was receiving wound and catheter care from Home Health.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
12/04/2024 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241204090408

FACILITY NAME:GRACIOUS CARE HOMEFACILITY NUMBER:
331880740
ADMINISTRATOR:BRANDON MARQUEZ GUTIERREZFACILITY TYPE:
740
ADDRESS:12515 HUDSON RIVER DRIVETELEPHONE:
(951) 444-6651
CITY:EASTVALESTATE: CAZIP CODE:
91752
CAPACITY:6CENSUS: 2DATE:
06/20/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator - Brandon MarquezTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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2
3
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5
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8
9
Facility staff failed to seek timely medical attention for resident
INVESTIGATION FINDINGS:
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5
6
7
8
9
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12
13
Licensing Program Analyst (LPA) Mary Rico and conducted unannounced visit to deliver findings for the allegations listed above. LPA Administrator Brandon Marquez and explained the purpose of the visit. The investigation consisted of staff interviews, and medical records.

Allegation, Facility staff failed to seek timely medical attention for resident.

Evidence shows that facility staff did not seek timely medical attention for R1. Based on medical records, during the night on 12/1/24 R1 had removed catheter. The following morning on 12/2/24 a home health nurse was unsuccessful in attempt to reinsert the catheter. R1 was not transported to the hospital until 12/2/2024 approximately 2000 hours. During staff interviews, the Licensee and Administrator where unsure why their facility staff did not have the urgency to call sooner.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20241204090408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/20/2025
NARRATIVE
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Based on the evidence gathered during today’s investigation, the one (1) allegation listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation are valid because the preponderance of evidence the standard has been met.

During today’s visit, one (1) deficiency were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to Administrator Brandon Marquez along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20241204090408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2025
Section Cited
CCR
87411(a)
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87411(a)Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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The licensee has agreed to conduct a staff training for proper emergency procedures and send LPA proof of staff attendance
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This requirement is not met as evidenced based on interview and document review, the licensee did not comply with the section cited above evidenced by failing to seek medical attention in a timely manner for R1, which poses an immediate health, safety, or personal rights risk to persons in care.
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POC due date 6/23/2025
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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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20241204090408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/20/2025
NARRATIVE
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Based on the evidence found during the investigation, the one (1) allegation listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Brandon Marquez.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5