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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881283
Report Date: 06/07/2024
Date Signed: 06/07/2024 12:33:57 PM

Document Has Been Signed on 06/07/2024 12:33 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:GRACE HOME TAVELFACILITY NUMBER:
331881283
ADMINISTRATOR/
DIRECTOR:
HANH, JENNIFERFACILITY TYPE:
740
ADDRESS:35224 TAVEL STTELEPHONE:
(714) 814-4287
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 6CENSUS: 6DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Jennifer Hahn - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Jennifer Hahn, Administrator, and discussed the purpose of the visit. The facility is a (5) bedroom, (3) bathroom, Residential Care Facility for Elderly (RCFE) with a license capacity of (6), and a current census of (6). LPA conducted a general inspection of facility, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by the Community Care Licensing Division (CCLD). Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. The facility is maintained at a comfortable temperature. Resident bedrooms were furnished with mattresses, night stands, chairs, storage space, and sufficient lighting. Resident bathrooms were maintained clean and fixtures were operating properly. The hot water temperatures in the bathrooms measured 106 degrees F and were equipped with grab rails and slip mats. The facility maintains a sufficient supply of bed linen, towels, emergency supplies and personal hygiene products for residents in care. The facility is equipped with laundry equipment, telephone service, and a centralized fire/carbon monoxide system. Posters such as personal rights, the Community Care Licensing complaint poster, Ombudsman poster, and the disaster plan, facility license, and resident personal rights were posted in a common area. Cleaning supplies, toxins, and sharps were kept locked and inaccessible to residents in care.

Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply is sufficient for number of residents in care. Facility refrigerators and freezers were maintained in healthful manner.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: GRACE HOME TAVEL
FACILITY NUMBER: 331881283
VISIT DATE: 06/07/2024
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Care & Supervision: The facility has care staff coverage, 24 hours a day, 7 days a week. All staff working in the facility have criminal record clearance through the Department.

Medical Services: Medications were labeled and centrally stored in a locked cabinet inaccessible to residents in care.

Record Review: LPA reviewed (6) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed (3) staff files for First Aid/CPR certifications, training, employee personnel documentation and health screenings.

Based on observations and records reviewed, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where reports (LIC809 & LIC9102) were discussed and a copy provided to the Administrator at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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