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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881256
Report Date: 03/19/2025
Date Signed: 03/19/2025 02:35:11 PM

Document Has Been Signed on 03/19/2025 02:35 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:AGING GRACE SENIOR LIVING FACILITY LLCFACILITY NUMBER:
361881256
ADMINISTRATOR/
DIRECTOR:		MARTIN, BRITTANYFACILITY TYPE:
740
ADDRESS:11539 HAWTHORNE AVENUETELEPHONE:
(442) 316-3650
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 6DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Brittany MartinTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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Licensing Program Analysts (LPAs) Magda Malcore and Eldin Serrano made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPAs met with Jessica Berumen, caregiver, were granted entry to the facility, and discussed the purpose for the visit. Administrator, Brittany Martin, arrived shortly after to the facility. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (6), and a current census of (6). LPAs conducted a general inspection of facility, which included, but was not limited to, the following:

Operation/Physical Plant: The facility is operating in the capacity approved by 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's outdoor activity space is enclosed with a self-latching gate. The facility is maintained at a temperature of 77 degrees F. Resident bedrooms were furnished with beds, bed linen, night stands, chairs, and sufficient lighting. Resident bathrooms were maintained clean, fixtures were operating properly, and equipped with non-skid mats. The hot water temperatures in the bathrooms measured at 116.2 degrees F. The facility is equipped with smoke detectors and carbon monoxide alarms, two (2) fully charged fire extinguishers, laundry equipment, hallway night lights, and telephone service. The facility has posted in a common area Community Care Licensing complaint poster, Ombudsman poster, resident personal rights, activity schedule, menu, facility license, and emergency telephone numbers. Sharps, cleaning supplies, and other chemicals were kept locked and inaccessible to residents in care. The facility staff schedule reflects 24 hours a day, 7 days a week staff coverage.

Food Service: Kitchen and dining areas were maintained clean. Non-perishable and perishable food supply was sufficient for number of residents in care. Cups, plates, and utensils were sufficient for number of residents in care.

Health Related Services: The facility maintains record of resident’s medications and medications were centrally stored in a locked medication room. The facility maintains a first aid kit with first aid manual. ***continued***

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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
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: AGING GRACE SENIOR LIVING FACILITY LLC
FACILITY NUMBER: 361881256
VISIT DATE: 03/19/2025
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Record Review: Resident files reviewed had admissions agreements, physician’s reports, appraisals, needs and services plans. Staff files reviewed had First Aid/CPR certifications, criminal record clearances, job training, and health screenings. The Administrator’s certification, facility’s insurance, infection control plan, disaster and emergency plan are up-to-date.

No deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report (LIC809) was discussed and a copy provided to Administrator Martin, at the conclusion of the visit.

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

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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