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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530233
Report Date: 11/07/2024
Date Signed: 11/07/2024 11:23:48 AM

Document Has Been Signed on 11/07/2024 11:23 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 BACHELOR PEAKFACILITY NUMBER:
335530233
ADMINISTRATOR/
DIRECTOR:		HAHN, JENNIFERFACILITY TYPE:
740
ADDRESS:32967 BACHELOR PEAK STTELEPHONE:
(714) 814-4287
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 6CENSUS: 0DATE:
11/07/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Applicant/Administrator Jennifer HahnTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 11/07/2024 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility for the purpose of a Prelicensing Visit. LPA met with Applicant/Administrator Jennifer Hahn. An initial application for license to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 03/05/2024 for a total capacity of six (6). Fire clearance was granted on 07/30/2024 for six (6) bedridden. LPA Brown observed the following:

Structure:
Facility's a one (1) level house with six (6) bedrooms; five (5) bedrooms for residents and one (1) staff bedroom, three (3) resident/staff bathrooms, living room, dining area, laundry room and kitchen. There is an attached two (2) car garage.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control the entire house.
Bedrooms:
Each resident bedrooms accommodate any bedridden resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, lamps, adequate lighting, and an operable combined smoke and carbon monoxide alarm.
Bathrooms:
The three (3) staff/resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. LPA Brown tested the water temperature in the resident/staff bathrooms. LPA verified water temperature was measured at 111.12 degrees Fahrenheit.

***CONTINUED ON LIC 809C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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
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 BACHELOR PEAK
FACILITY NUMBER: 335530233
VISIT DATE: 11/07/2024
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***CONTINUED FROM LIC 809***
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. Applicant/Administrator Hahn reported that they will have more than seven (7) days’ supply of non-perishable foods and more than two (2) days’ supply of perishable foods. There’s an adequate seating for meals for all residents. Laundry room with washer and dryer. Laundry detergents and cleaning supplies are stored in the laundry room that will not be accessible to residents.
Living/Family room:
There’s a living/family room with adequate seating for all residents and a working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in each resident closet.
Yards/Outside:
Patio furniture for outdoor seating observed. Side Gate on the left side of the facility. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted in the living/family room hallway. Ombudsman poster, Let-Us-No poster, Personal Rights, Emergency Disaster Plan, Rights to Resident Council, Personal Property/Theft and Loss and Labor Laws were observed.
Dementia Care Plan:
LPA Brown observed and reviewed the Dementia Care Plan during the visit.

General items:
One (1) fire extinguisher was charged and located in the hallway of the facility. Dual smoke alarms and carbon monoxide detectors were tested and were observed to be in working order. Resident records will be stored in a locked cabinet in the living/family room hallway. First Aid kit with required components, First Aid book and locked cabinet for medication storage was observed. LPA Brown observed a facility phone and was operational as evidenced of LPA dialing the number. The phone number designated for the facility is 951-599-0088. There is enough Emergency water supply observed and the required 72-hour emergency food supply were observed from the regular food supply. ***CONTINUED ON LIC 809C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 BACHELOR PEAK
FACILITY NUMBER: 335530233
VISIT DATE: 11/07/2024
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***CONTINUED FROM LIC 809C**
Component III was completed on this day as well. LPA Brown observed activities for the residents such as books and games. Additionally, upon entry, LPA Brown observed the facility having Visitor Sign In/Sign Out Sheet and Resident Sign In/Sign Out Sheet.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, to ensure the health and safety of residents in care. Applicant/Administrator Hahn has satisfied all requirements in accordance with Title 22, California Code of Regulations. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report, LIC809 was discussed, reviewed and provided to Applicant/Administrator Jennifer Hahn.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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