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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700317
Report Date: 01/26/2022
Date Signed: 01/26/2022 04:23:00 PM

Document Has Been Signed on 01/26/2022 04:23 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GRACE HOME IIFACILITY NUMBER:
342700317
ADMINISTRATOR:NELSON JACINTOFACILITY TYPE:
740
ADDRESS:9260 LOMA LANETELEPHONE:
(916) 607-6225
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 24CENSUS: 22DATE:
01/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Nelson JacintoTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced on 01/26/2022 to conduct a case management deficiency visit. LPA met with Administrator, Nelson Jacinto and explained the purpose of the visit. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 respirator.

LPA discussed with Administrator the following:
On 01/24/2022 the Department received an incident report from an AWOL incident that happened on 1/19/2022. C1 walked out of facility and spent the night at a local Macy's. Licensee notified sheriffs department who issued a missing persons report. On the morning of 1/20/2022 somebody called 911 for her. Licensee transported her back to facility that day. LPA reviewed C1's file/Pysician's Report and found she is unable to leave the facility unassisted

The Department is issuing one (1) deficiency as a result. Deficiencies can be found on LIC-809-D per California code of regulations, title 22.

Exit interview conducted. Copy of report and appeal rights provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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 2
Document Has Been Signed on 01/26/2022 04:23 PM - It Cannot Be Edited


Created By: Jacob Williams On 01/26/2022 at 11:35 AM
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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: GRACE HOME II
FACILITY NUMBER: 342700317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2022
Section Cited
CCR
85078(a)(1)

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85078(a)(1): Responsibility for Providing Care and Supervision-The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
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Licensee agrees to implement room checks every 60 minutes when C1 is inside C1's room, and when outside of C1's room, C1's should be in line of sight. Licensee will provide Letter of Understanding POC to LPA by COB on 1/27/2022.
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This requirement was not met as evidenced by: documentation, record review and interview. Administrator and facility staff failed to supervise client in care resulting in C1s unsupervised AWOL, who then stayed overnight at a local mall. This poses an immediate risk to clients in care.
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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:Anthony Perez
LICENSING EVALUATOR NAME:Jacob Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022


LIC809 (FAS) - (06/04)
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