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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700317
Report Date: 06/04/2025
Date Signed: 06/04/2025 01:01:47 PM

Document Has Been Signed on 06/04/2025 01:01 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GRACE HOME IIFACILITY NUMBER:
342700317
ADMINISTRATOR/
DIRECTOR:		NELSON JACINTOFACILITY TYPE:
740
ADDRESS:9260 LOMA LANETELEPHONE:
(916) 607-6225
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 24CENSUS: 22DATE:
06/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Nelson JacintoTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains, Licensing Program Manager (LPM) Laura Munoz, and Regional Manager (RM) Alycia Rayner arrived on June 4, 2025 to conduct the annual inspection. Department met with administrator, Nelson Jacinto and explained the purpose of today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. Department reviewed five (5) residents and two (5) staff files. All required postings were observed.

Department and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. Grab bars were present at the toilet and in the shower. Department checked the kitchen area for the ability to prepare and store food. Department observed the area used for medication to be locked and inaccessible to residents. Department observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguishers were last serviced on 12/5/24 and were ready for emergency use.

Department found multiple concerns, therefore, deficiencies were observed and cited per Title 22, CCR Regulations as listed on LIC809-D. Civil penalties will be assessed if facility will not comply with all POC requirements as issued today.

Exit interview conducted. Copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Lavinia Muscan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/04/2025 01:01 PM - It Cannot Be Edited


Created By: Lavinia Muscan On 06/04/2025 at 12:16 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACE HOME II
FACILITY NUMBER: 342700317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as bedbug spray and cleaning chemicals were accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2025
Plan of Correction
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Licensee shall send a letter of understanding of this regulation and shall conduct staff training. All POC documents are due by 6/5/25.
Type A
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as 2 out of 5 residents require special diets and facility was not following the diet orders, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2025
Plan of Correction
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Licensee shall send a letter of understanding of this regulation, will draft a plan on how facility will follow dietary orders for residents per their physicians, and shall conduct staff training. All POC documents are due by 6/5/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Lavinia Muscan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/04/2025 01:01 PM - It Cannot Be Edited


Created By: Lavinia Muscan On 06/04/2025 at 12:16 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACE HOME II
FACILITY NUMBER: 342700317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)
General Food Service Requirements
(b) The following food service requirements shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, no snacks were available to residents and the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2025
Plan of Correction
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Licensee shall send a letter of understanding of this regulation, will draft a plan on how facility will provide snacks for residents, and shall conduct staff training. All POC documents are due by 6/5/25
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as multiple food items were found to have expired dates, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2025
Plan of Correction
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Licensee shall send a letter of understanding of this regulation, and will make sure all food items are in good qualily and not expired, and shall conduct staff training. All POC documents are due by 6/5/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Lavinia Muscan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/04/2025 01:01 PM - It Cannot Be Edited


Created By: Lavinia Muscan On 06/04/2025 at 12:16 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACE HOME II
FACILITY NUMBER: 342700317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on department inspection, resident (R1) was missing a side table, chair, lamp as required, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2025
Plan of Correction
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Licensee shall send a letter of understanding of this regulation, and will make sure all residents have reqiured furniture per regulation, and shall conduct staff training. All POC documents are due by 6/18/25
Type B
Section Cited
CCR
87412(b)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 3 out of 5 staff files do not contain a physical and TB test as required, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2025
Plan of Correction
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Licensee shall send a letter of understanding of this regulation, and will make sure all staff have a physical and TB test per this regulation, and shall conduct staff training. All POC documents are due by 6/18/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Lavinia Muscan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/04/2025 01:01 PM - It Cannot Be Edited


Created By: Lavinia Muscan On 06/04/2025 at 12:16 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACE HOME II
FACILITY NUMBER: 342700317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)
Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, during inspection, chairs and personal belongings for residents were found to be locked up, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2025
Plan of Correction
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Licensee shall send a letter of understanding of this regulation, and will draft a plan on how the facility shall ensure residents personal rights are met per regulation, and shall conduct staff training. All POC documents are due by 6/18/25.
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, during inpection, no planned activities were available for residents as required, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2025
Plan of Correction
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Licensee shall send a letter of understanding of this regulation, and will draft a plan on how the facility shall ensure residents have planned activities per regulation, and shall conduct staff training. All POC documents are due by 6/18/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Lavinia Muscan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
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