Gracious Care Home

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver the findings on the allegation listed above. LPA met with staff Ricardo Rojas Garcia and explained the purpose of today’s visit. The investigation consisted of staff interviews, resident interviews and record review. For the allegation, Staff are recording/videotaping residents without consent. During staff interviews 2 out of the 2 staff stated they do not take pictures or videos without resident consent. During resident interviews 3 out of the 4 residents stated staff have not taken pictures or videos of them. One resident was unable to collaborate on the allegation listed above. During record review, LPA observed residents, and their responsible party have approved for pictures or videos to be taken. UnsubstantiatedRead the full finding— CDSS inspection report, February 6, 2026 · control 56-AS-20260122161815

Licensing Program Analyst (LPA) Mary Rico conducted unannounced visit to deliver findings for the allegations listed above. LPA met with Administrator Brandon Marquezand explained the purpose of the visit. The investigation conducted by Department staff consisted of staff, resident interviews and review of pertinent records. Allegation, Resident developed a pressure injury due to staff neglect. Evidence shows that R1 sustained a Stage 4 pressure injury on sacrum. However, the wound developed prior to R1 moving into the facility. Evidence show that R1 sustained a Stage 4 pressure injury on Sacrum prior to being placed at Gracious Care Home. Evidence shows that R1was receiving wound care services from Home Health. In addition, Licensed Vocational Nurse (LVN) confirmed they would visit R1 and provided wound care along with catheter care. During staff interviews 2 out of the 3 staff stated R1 was receiving wound and catheter care from Home Health. UnsubstantiatedRead the full finding— CDSS inspection report, June 20, 2025 · control 56-AS-20241204090408

This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegation mentioned above. During the course of the investigation, interviews were conducted, and a review of resident records was completed. On 04/06/2023 it was alleged that facility staff hit R1 on the back of the head daily resulting in a bump on the back of their head. A specific staff is not identified. Two resident interviews were conducted. Two out of two residents interviewed could not provide any information regarding physical abuse due to cognitive status. LPA interviewed S1. S1 is the primary caregiver of the facility at this time. S1 denies having hit R1 on the back of the head. Interview with R1's responsible party revealed that R1 had the bump on the back of the head following a medical event in August 2022 and there is no observable change to the bump. UnsubstantiatedRead the full finding— CDSS inspection report, December 14, 2023 · control 56-AS-20230406152853

Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent visit on this day to deliver an amended report to the above-mentioned complaint allegations. LPA Amy Goldenberg completed the visit on 12/12/2023. Findings for the allegations are still unsubstantiated. During the course of the investigation, interviews were conducted, a review of resident records was completed and copy of pertinent documents obtained. It is alleged that Licensee Sandy Zhao and an unknown staff denied a family member visitation with R1. Investigation revealed the following information: Interview with the reporting party revealed that on 06/20/2022 a visitor attempted to visit R1 and the facility staff would not allow the visitor access into the home and law enforcement was called to gain access. There are no court orders preventing anyone visitation with R1. UnsubstantiatedRead the full finding— CDSS inspection report, December 12, 2023 · control 56-AS-20220621092755

This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above. It is alleged that the facility is not following COVID-19 guidelines. Investigation included review of the facility emergency disaster plan and COVID-19 mitigation plan received 07/19/2021. LPA observed on the initial visit conducted on 08/19/2021 the following: Staff took LPA temperature, provided hand sanitizer, and had a sign in procedure. LPA was granted entry. Facility staff were all wearing masks. The facility has all the elements of their COVID-19 Mitigation Plan in place. Interview with staff during the time of the pandemic, revealed that visitations were not limited. However, the facility requested if family can call and let them know when they are going to arrive and as recommended if they had traveled or were not vaccinated to obtain a negative covid test. All visitation took place outside and weRead the full finding— CDSS inspection report, July 18, 2023 · control 18-AS-20210817110059

This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above. During the course of this investigation LPA received and reviewed R1's hospice records dated 02/15/2021 through 02/25/2021. LPA reviewed R1's pre placement appraisal dated 2/16/2021, R1's physician report dated 02/12/2021, and R1's post acute order summary report dated 2/15/2021. Investigation included LPA tour of the facility on 03/10/2021, 06/21/2023, and 07/12/2023. Tour consisted of review of medications, assessment of food supply, and observing availability of food and drink for the residents. Facility tour dates revealed that the facility had sufficient supply of perishables and non perishables on hand. On 7/12/2023 LPA observed the lunch meal being served. Lunch was consistent with nutritional guidelines, hotdog on a bun, potatoes, fruit, and medium glass full of a juice and water were being served.Read the full finding— CDSS inspection report, July 12, 2023 · control 18-AS-20210301143619