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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881283
Report Date: 05/18/2022
Date Signed: 05/18/2022 11:19:54 AM

Document Has Been Signed on 05/18/2022 11:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:GRACE HOME TAVELFACILITY NUMBER:
331881283
ADMINISTRATOR:HANH, JENNIFERFACILITY TYPE:
740
ADDRESS:35224 TAVEL STTELEPHONE:
(714) 814-4287
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 6CENSUS: 0DATE:
05/18/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Jennifer Hanh-AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. I met with Administrator Jennifer Hanh. An initial application to operate an Residential Care Facility Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 3/14/2022 for a total capacity of six( 6) four (4) bedridden and two (2) non ambulatory.
Fire clearance was granted on 04/14/2022. LPA Allen observed the following:
Structure:
Facility is a house with five (5) resident bedrooms, three(3) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway a to control entire house.
Bedrooms:
Master bedroom and bedroom #3 can be used for bedridden only per fire clearance.
All bedrooms including the master bedroom and bedroom #3 will accommodate bedridden resident and are adequately furnished with bed, chair, closet, appropriate linens, adequate lighting,
Bathrooms:
All three (3) bathrooms have working toilets, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. The water temperature was measured at 118.0 degrees Fahrenheit.
Kitchen/Laundry:
The kitchen has adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen drawer next to sink. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. Kitchen..
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: GRACE HOME TAVEL
FACILITY NUMBER: 331881283
VISIT DATE: 05/18/2022
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There was sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located near the garage. Laundry detergents and cleaning supplies were observed in closet near the garage secured in a locked closet..

Living/Family room:
There was a living/family room with a TV and adequate seating for all clients.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.

Yards/Outside:
There is currently covered seating area in the front of the house and patio cover will be delivered on 5/19/2022 for backyard. There is a gate on the right side and left side of the property with a self-latching from the exterior doors. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the main hallway.

General items:
There was fire extinguishers and carbon monoxide detectors are in good conditions. Client records will be stored in a locked cabinet in the family room area.
First Aid kit with required components are located in kitchen drawer.
Medication will be locked in a cabinet in living/dinning area.
LPA observed a facility phone and it was verified to be operational . Emergency water supply and food was observed.
An exit interview was conducted, and a copy of this report was given to the administrator Jennifer Hanh-Administrator
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC809 (FAS) - (06/04)
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