<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604432
Report Date: 10/17/2025
Date Signed: 10/17/2025 03:11:02 PM

Document Has Been Signed on 10/17/2025 03:11 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HOUSE OF GRACE FOR SENIOR CAREFACILITY NUMBER:
374604432
ADMINISTRATOR/
DIRECTOR:		PENOLA, HELENITA B.FACILITY TYPE:
740
ADDRESS:971 RUTGERS AVE.TELEPHONE:
(858) 294-3410
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 6CENSUS: 6DATE:
10/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Caregivers Urdaneta Balila and Geraldine Penola and Administrator Helenita PenolaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregivers Urdaneta Balila and Geraldine Penola. Administrator Helenita Penola arrived later during the visit. The facility's license shows a maximum capacity of six (6) non-ambulatory residents. Additionally, the facility has a hospice waiver for two (2). During today’s inspection there were six (6) residents in care.
 
LPA and Administrator Penola toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Common bathroom sink 1 was 108F and common bathroom sink 2 was 109F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents in care.

[Continued on LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2025
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 4
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)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HOUSE OF GRACE FOR SENIOR CARE
FACILITY NUMBER: 374604432
VISIT DATE: 10/17/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
[Continued from LIC 809]

No toxic chemicals or poisons were accessible to clients.  Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Administrator Penola, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were present and purchased within the last 12 months. First aid kit was complete and readily accessible. Last staff emergency drill conducted was on 9/5/25 for the topic of fires and mass casualty disasters. Required licensing postings were observed in visible areas of the facility. LPA observed residents to be attended to timely and treated with respect. LPA observed a meal be prepared and served to residents as well as assistance with feeding as needed.

LPA interviewed one (1) staff and two (2) outside source visitors and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. LPA noted that one (1) staff member (identified as S1) was included on the staff roster but did not have a background clearance on file. Another staff member (Identified as S2) had an Excluded determination on their background check, and thus may not be present or work at any licensed facility.

Two Type A Deficiencies cited per California Code of Regulations, Title 22, Division 6 on the attached LIC 809-D. In addition, a Civil Penalty for each of the two Type A violations are being assessed for Zero Tolerance Violations regarding Criminal Record Clearances and are noted on the two (2) attached LIC 421BG forms in the combined amount of $1,000.00. LPA ensured S2 was removed from the property and informed the licensee that S1 may not be present at the facility until S1 receives an eligible background clearance from the California Department of Social Services (CDSS). In regards to S2, LPA issued a Decision and Order letter to the Licensee and provided consultation for next possible steps.

Two (2) deficiencies were cited during the inspection. An exit interview was conducted with Administrator Penola to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/17/2025 03:11 PM - It Cannot Be Edited


Created By: Arian Golbakhsh On 10/17/2025 at 02:03 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HOUSE OF GRACE FOR SENIOR CARE
FACILITY NUMBER: 374604432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355(e): "All individuals subject to a criminal record review [...] shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department"
This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and interview, the licensee did not comply with the section cited above in ensuring all staff had eligible background clearance prior to working at the facility, which poses an immediate health, safety and personal rights risk to 6 out of 6 persons in care.
POC Due Date: 10/24/2025
Plan of Correction
1
2
3
4
Licensee will submit proof of submitted request for a background check for Staff 1 (S1) and share with LPA by POC due date.
Type A
Section Cited
HSC
1569.58(a)(2)
(a) The department may prohibit any person from being a licensee, owning a beneficial ownership interest of 10 percent or more in a licensed facility, or being an administrator, officer, director, member, or manager of a licensee or entity controlling a licensee, and may further prohibit any licensee from employing, or continuing the employment of, or allowing in a licensed facility, or allowing contact with clients of a licensed facility by, any employee, prospective employee, or person who is not a client and who has done any of the following: (2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA file review and interview, the licensee did not comply with the section cited above by employing a staff member (identified as S2) with a lifetime Exclusion Order, which poses an immediate health, safety and personal rights risk to 6 out of 6 persons in care.
POC Due Date: 10/18/2025
Plan of Correction
1
2
3
4
LPA ensured that S2 was removed from the facility. Licensee will review applicable Title 22 regulation 87355 and California Health and Safety Code 1569.58 and submit proof of review and understanding and submit to LPA by 10/24/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4