House of Grace 3

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual inspection using the Compliance and Regulatory Enforcement (CARE) Tool. Upon arrival, LPA was greeted by Maria Macalino and explained the purpose of the visit. Administrator Michelle Aguirre arrived shortly thereafter. The facility is licensed to serve residents ages sixty (60) and older, with an approved capacity of six (6) residents, all of whom may be non-ambulatory. The facility is also approved to care for up to six (6) hospice residents. At the time of the inspection, six (6) resident were receiving hospice care. Facility Tour & Observations Required postings, including Personal Rights (LIC 613C), Ombudsman information, the Complaint Poster (PUB 475), and the nondiscrimination notice were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms or weapons were present. Physical Plant The facility is located in a residential area and is a one-story home consisting of four (4) resident bedrooms, two (2) restrooms one of which is a private restroom along with a living room, kitchen, dining area, laundry room, garage, and front and backyard areas.LPA observed that all four (4) resident bedrooms contained the required furnishings, including a bed, mattress, linens, dresser, chair, and appropriate lighting. Cleaning supplies and toxic substances were inaccessible to residents and locked in hallway closet.Bathrooms were clean and equipped with the required grab bars in the showers and near the toilets, as well as non-skid mats. Hot water temperatures measured 107.6°F in bathroom (1) and 109.2°F in bathroom (2), which are within the required range of 105–120°F. **Continued on LIC809C** Extra linens and towels were stored in a hallway cabinet. Smoke and carbon monoxide detectors were tested and found to be functional. Fire extinguishers were observed in the hallway by the garage entrance and inside the garage. No bodies of water were present on the premises. The backyard offered shaded seating. All indoor and outdoor passageways and exits were clear and unobstructed. Food Service Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees °F and freezer 0-degree °C) with sufficient supply of 2-day perishable and 7 days non-perishable food. Fresh produce, proteins, and dry goods were stocked. Knives and were observed in a locked kitchen drawer. Health-Related Services & Records Six (6) resident files were reviewed and contained current required documents, including Admission Agreements, Pre-Placement Appraisals, Consents, Physician’s Reports with TB results and ambulatory status, and Rights Acknowledgments. Six (6) residents’ medications were reviewed; medications were observed to be centrally stored and kept locked in the hallway closet. However, based on record review, all six (6) resident files did not contain updated re-appraisals as required by regulation 87463(a). Disaster Preparedness Last fire/earthquake drill was conducted on October 5, 2025, with logs available. LIC 610D Emergency Disaster Plan was posted on hallway bulletin board. Emergency supplies (water, food, flashlights, batteries, first aid) were observed in the garage. Infection Control Plan was updated. Personnel Records & Training Three (3) staff files were reviewed and included documentation of criminal record clearances, CPR/First Aid certification, and TB screenings. Administrator Certificate for Michelle Aguirre was verified and is valid through August 28, 2026. However, based on record review, staff were missing the required annual training as mandated by regulation. **Continued on LIC809C** Insurance Liability insurance was in compliance with an expiration date February 21, 2026. An exit interview was conducted with,Maria Macalino. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. Michelle Aguirre, Administrator was advised of the nature of the deficiencies, the regulatory basis, and the required Plan of Correction (POC). Michelle Aguirre, Administrator agreed to submit proof of correction by the due dates specified. A copy of this report, LIC 809D/809C, and appeal rights will be provided via email.the state’s words, verbatim · CDSS document, Dec 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by Caregiver Mario Macalino. Administrator Michelle Aguirre arrived shortly after. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mats in showers. Showers were observed to be wheelchair accessible. Facility has video surveillance inside common areas. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 01/02/2025 &11/15/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency water supply located in garage. See 809-C Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication cabinet and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Staffing: Administrator Certificate for Michelle Aguirre is pending renewal and awaiting final approval. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for three (3) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for six (6) non-ambulatory. This facility may retain no more than six (6) hospice residents. There were five (5) residents under hospice care during inspection. Resident Records/Incident Reports: LPA reviewed resident files for six (6) residents in care. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were observed during visit. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 7, 2025

Allegation investigated: Facility failed to meet residents dietary needs. Facility failed to communicate with resident's family. Facility overmedicated resident.

*** This licensing report issued on 08/13/2024 supersedes that licensing report dated 07/23/24, LPA Vaid obtained additional information, however, the investigation findings will remain the same*** Licensing Program Analyst (LPA) Vaid conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met Michelle Aguirre (Administrator) and explained the reason for the visit. During last visit on 04/17/2023, LPA Villalobos requested and obtained a copy of the staff and client roster, LPA toured the physical plant, interviewed residents #1-5 (R1-R5) and staff #1-3 (S1-S3). LPA collected documents from R1's file. On today’s visit LPA Vaid met with the administrator to deliver the findings. Toured physical plant with caregiver Maria Macalino and did not observe any Health and Safety conerns. Continued on 9099C...... Unsubstantiated Regarding the allegation: Facility failed to meet resident’s dietary needs. It is alleged the facility staff were giving the resident processed food and milk products, and staff were not complying with residents restricted diet, as resident is lactose intolerant. During investigation, LPA interviewed five (5) of five (5) residents, all five residents could not corroborate the allegation. Three (3) of three (3) staff were interviewed and denied the allegation. Hospice services employees could not corroborate this allegation, the hospice staff made visits during non-meal hours. According to the records reviewed, R1 was given a diet that was designed and approved by R1’s physician. Review of Resident #1 (R1) Physicians Report dated 01/27/23 indicates milk and milk product, however the physician report does not indicate R1 is on a modified or R1s diet restricts processed food or milk products. Review or R1 facility file, including R1s hospice care plan dated 03/06/23 indicates that R1 was on a mechanical soft diet and does not mention restriction of processed food or dairy products. The facility made necessary adjustments to R1s meal plan. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Facility failed to communicate with residents’ family. It is alleged that the facility did not properly communicate with the R1s family regarding issues that arose while R1 resided in the facility. During the investigation, LPA interviewed five (5) of five (5) residents, all five residents could not corroborate the allegation. Three (3) of three (3) staff were interviewed and denied the allegation. Two Hospice staff stated the communication with family was positive, S1 family was able to communicate with hospice services staff regularly. According to LPAs interviews, R1’s responsible party, was not aware of any lack of communication issues between R1s family members and the facility. Interviews with facility staff indicated that the administrator and staff informed R1s family of issues concerning R1, such as R1s refusal to take medications. The facility staff would reach out to the R1s family to see if the family members could talk R1 into taking their meds. R1s would exhibit behaviors, such as random outbursts and claiming to be soiled when R1 was not soiled. The facility would inform R1s family of R1s behavioral issues and R1s family would assist in speaking with R1. Based upon the investigation, interviews with residents and staff, review of R1s facility file, the investigation did not reveal any evidence to support that staff were not communicating with R1s family. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. Continued 9099C....... Regarding the allegation: Facility over-medicated residents. It is alleged that the facility was over-medicating R1 to keep R1 quiet. The facility administrator and staff deny the allegation. During the investigation, LPA interviewed five (5) of five (5) residents, all five residents could not corroborate the allegation. Three (3) of three (3) staff were interviewed and denied the allegation. Hospice staff could not corroborate this allegation, the hospice staff was not present during medication administration. Per interviews with facility staff, staff reported that staff gave R1 medications as prescribed by R1s physician. LPAs interview with R1 authorized representative, revealed that when R1 was taken to the hospital, the hospital observed R1 was taking several different types of medications prescribed by different doctors, and felt the combination of those medications were harming R1, therefore, a change of prescriptions was implemented to meet R1’s medication needs. Per R1s authorized representative, R1s was discharged from the hospital, and based on the hospital recommendation, R1s family removed R1 from the facility and placed R1 into new facility. Per review of R1s file, interviews with staff and residents the investigation did not reveal that staff were overmedicating R1 and staff were following R1 physician orders. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and copy of this report was left with the Administrator Becky Sinclair.the state’s words, verbatim · CDSS document, Aug 13, 2024 · control 28-AS-20230411101826

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 07/30/2024. LPA Ramirez was greeted by Caregiver Marianaila Macalino and explained the purpose of the visit. Back up Administrator Rebecca Sinclair arrived shortly after. Case Management-Deficiencies findings: On 7/23/2024, LPA Vaid conducted a subsequent complaint investigation, and it was revealed to LPA Vaid that the facility was experiencing an active epidemic outbreak. Per Title 22 , Division 6, Chapter 8, Article 04, Operating Requirements, 87211(a)(1)(2) Reporting Requirements- (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. (C) The use of an Automated External Defibrillator. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. Per staff interviews, Resident#1 (R1) tested positive for a communicable disease on 7/22/24. On 7/23/24, (R2), (R3) and (R4) tested positive for a communicable disease. During records review, LPA Ramirez could not locate a report in R1, R2, R3 and R4’s file regarding an incident that threatens their health on 7/22/24 and 7/23/24. This licensing agency did not receive notification of a epidemic outbreak within 24 hours from 7/23/24. LPA Ramirez will issue a Type B deficiency based on records reviewed and interviews with staff. One (1) deficiency was cited during visit. A copy of this report and appeals rights was provided.the state’s words, verbatim · CDSS document, Jul 30, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(2) · Plan of correction due date: Aug 13, 2024

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven* Licensee will send report and retrain by 8/13/24. case.(A)Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.(C) The use of an Automated External Defibrillator. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.the state’s words, verbatim · CDSS document, Jul 30, 2024

Plan of correction: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the-

Allegation investigated: Facility failed to meet residents dietary needs. Facility failed to communicate with resident's family. Facility overmedicated resident.

Licensing Program Analyst (LPA) Vaid conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met Michelle Aguirre (Administrator) and explained the reason for the visit. During last visit on 04/17/2023, LPA Villalobos requested and obtained a copy of the staff and client roster, LPA toured the physical plant, interviewed residents #1-5 (R1-R5) and staff #1-3 (S1-S3). LPA collected documents from R1's file. On today’s visit LPA Vaid met with the administrator to deliver the findings. Regarding the allegation: Facility failed to meet resident’s dietary needs. It is alleged the facility kept giving dairy to R1 when she was lactose intolerant. According to the records reviewed, R1 was given a diet that was designed and approved by R1’s physician. The facility made necessary adjustments to the resident meal plans, as reviewed in the records. CONTINUED ON PAGE 809C Unsubstantiated Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding the allegation: Facility failed to communicate with residents’ family. It is alleged that the facility did not properly communicate with the family during issues arising from R1. According to records obtained, R1 responsible party was not aware of any communication issues with the facility. The administrator states, they informed the family of resident whenever there were issues like refusal to take medication, the facility would reach out to the family to see if they could talk her into taking their meds. Random outbursts from the R1, claiming to be soiled when they were not. The facility would inform the family when R1 was having behavior issues and need to talk her down, made notes of R1 progress and behavior changes. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding the allegation: Facility over-medicated residents. It is alleged that the facility was over-medicating R1 to keep her quiet. The facility denies this claim. Facility gave the medications that were prescribed to R1 by physician and were given as prescribed and ordered by doctors. Facility noted that combination of different medications prescribed by different doctors were making R1 agitated and forwarded the information to the family. R1's responsible party stated when R1 was taken to Kaiser, the hospital observed R1 was taking different medications from different doctors and felt the combination of those medications were harming R1 and needed a change of prescriptions to meet R1’s medication needs. The family removed R1 from the facility after her hospitalization at Kaiser and placed R1 into new facility. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted and copy of report was left with the Administrator.the state’s words, verbatim · CDSS document, Jul 23, 2024 · control 28-AS-20230411101826

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 12/27/2023. LPA was met by Caregiver MARIO MACALINO and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which six (6) may be non-ambulatory and approved hospice waiver for four (4). LPA OBSERVATIONS: The facility is a single-story dwelling located in a residential neighborhood and consist of three (3) resident bedrooms, one (1) staff bedroom, two (2) resident bathrooms, kitchen, dining room, living room, attached garage, staff office, front yard, and backyard. Front Yard: Front yard is well maintained, and no hazards were observed. Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. Kitchen sink water temperature was measured at 137.2 degree F. LPA Ramirez observed chemicals and cleaning solutions, located in under kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. Kitchen appliances were observed to be clean and in working order. LPA Ramirez observed Register of Facility Clients/Residents (LIC 9020) in clear plastic sleeve and was placed on kitchen cabinet. Dining Room/Living room/: Dining room was observed to contain one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed nearby thermostat in this area to read 77 degree F. Linen Closet: Contained plenty linens, towels, and hygiene products. Resident Rooms 2 - 4: LPA Ramirez inspected three (3) shared resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens. LPA Ramirez observed proper signage indicating the use of oxygen in two (2) out of the five (5) bedrooms. LPA Ramirez observed “Bedside Checklist” placed in bedrooms #3 and 4 (near entry and in plain view) that contained confidential personal and medical information for three (3) out of the six (6) residents in care. See 809-C Bathroom: Bathroom#1 water temperature was measured at 141.1 degrees F. LPA Ramirez observed grab bars and non-slip mats. LPA Ramirez observed one (1) grooming razor in bathroom cabinet drawer. Bathroom#2 located in bedroom#4 was measured at 138.6 degree F. Backyard: No hazards were observed. Plenty of shade and seating was observed. Centrally Stored Medications: Medications were observed to be stored in facility hallway closet and inaccessible to six (6) out of six (6) residents in care. Emergency Drills: Last documented emergency drill was conducted on October of 2023. Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable. Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for three (3) staff. Documented proof of initial dementia training required within the first 4 weeks of employment was not observed for one (1) out of the three (3) personnel records reviewed. Resident Files: Six (6) resident files were reviewed. Liability Insurance & Infection Control Plan: LPA Ramirez obtained a copy of liability insurance. LPA Ramirez obtained a copy of Infection Control Plan. Deficiencies and technical advisories are being cited. A copy of this report, 809-D, LIC 9120 and appeals rights was provided.the state’s words, verbatim · CDSS document, Dec 7, 2023

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.