Our Lady of Grace Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual required inspection and met with Licensee/Administrator (LIC/ADM) Rene Clemente and stated the purpose of the visit. The facility is licensed to serve adults 60 and over. Approved for 6 non-ambulatory, of which 1 may be bedridden in Room #1 or Room #3. Garage and level 2 is off limits. Waiver granted for 2 hospice care. During the visit, LIC/ADM stated that the current census is 6 residents, however 1 of the 6 is in the hospital. LPA observed 5 residents, 2 out of 5 is non-ambulatory, and 3 out of 5 were ambulatory. LPA toured the facility, including common areas, resident rooms, kitchen, bathrooms, driveway, and outdoor spaces and storage areas. Indoor temperature was within acceptable range of 70°F. The kitchen was sanitary and organized; knives and chemicals were locked. Food supply met requirements (2 days perishable, 7 days non-perishable). Kitchen water temperature measured with digital thermometer is at 105°F. Bathroom water temperature measured 110°F. During the inspection of the exterior perimeter, LPA observed outdoor furniture such as dining tables and chairs and a couch. LIC/ADM stated that residents and staff uses the outdoor area for activities and outdoor eating. Based on observation the outdoor walkways were free obstructions and debris. The emergency exit gate is functional. However, LPA observed a camping gas stove placed against the exterior wall of the house. LIC/ADM stated that the stove top is used for frying food instead of cooking inside. LPA suggested that due to fire risk LIC/ADM should place the gas stove top at an area with plenty of open space and no overhead branches. LIC/ADM relocated the camping gas stove top in an open area that has no overhead branches. During the interior inspection, LPA observed 2 bathrooms, 1 out of 2 is located near the garage area/hallway and 1 out of 2 is located near the dining area. Both bathrooms have grab bars and non-skid mats. Room 1, 2 and 3 are shared. Based on observation the resident rooms had adequate storage, sanitary and is kept organized by staff. 1 out of 5 residents has a half bed rails ordered by his/her physician. Medications were locked and inaccessible to residents; first aid kit was complete. laundry appliances were functional, and cleaning supplies were secured. Fire, smoke, and carbon monoxide systems were operational and tested each month by the staff, interior hallways were not obstructed. LPA inspected the food supply and observed that the refrigerator temperature is at 40 degree F and the freezer temperature is at 0 degree F. The facility has 2 days of perishable food and 7 days of non-perishable food. LPA observed that storage for the non-perishable food were in different places. LPA reviewed 3 resident and 3 staff records, including medication logs, admission agreements, care plans, personal and incidentals, health screenings, and training. All staff have required clearances and certifications. Based on document review, 3 out of 3 staff completed 12 hours of dementia care and the additional annual 8 hours dementia care training is on going. The facility conducts fire and earthquake drill the ast fire and earthquake drill practice training was on 07/18/2026 and 07/19/2026. The facility is equipped with panel fire alarm system and 2 fire extinguisher were inspected, No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with Licensee/Administrator Rene Clemente and a copy of the report was provided. end of report page 2 of 2the state’s words, verbatim · CDSS document, Sep 23, 2026

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced post-licensing inspection visit. LPA met with Licensee (LIC) Rene Clemente. Administrator Aries Geronimo was not present at the facility at the time of the visit and arrived shortly thereafter at around 9:10 a.m. The facility is licensed to serve adults age 60 and over. Approved for six (6) non-ambulatory of which one (1) may be bedridden in Room #1 or Room #3. Garage is off limits, Level 2 is off limits. The facility has a hospice waiver for two (2). LIcensee accompanied LPA during inspection of the facility. LPA observed the following such as but not limited to poster of If You See Something Say Something, personal rights, facility license in a visible area, menu, staff tasks, calendar, emergency call list, emergency disaster plan, and resident roster. LPA inspected 3 resident bedroom, garage, kitchen, dining area, living area. LPA inspected the facility exterior area. Hallways, walkways, exit routes was observed to be free from tripping hazard and not obstructed. Sharp objects, medications, chemicals, and disinfectants observed in a locked cabinet. LPA observed 4 residents at the time of the visit. 1 Out of 4 was observed in the living area watching TV, 2 out of 4 was observed in the dining area having breakfast and 1 out of 4 was inside his/her room watching TV. LPA observed 2 staff (S1 and S2) busy doing chores and assisting residents. page 1 of 2 see LIC 809C Facility temperature maintained at 70 degrees F. Resident bedrooms observed with beds, linens, adequate lighting, storage spaces for personal belongings. 2 out of 2 resident bathrooms were observed to have grab bars and anti skid mats. Water temperature maintained between between 111.5 to 117.3 degrees F. Facility has a sufficient supply of extra linens. Facility refrigerators temperature maintained at 40 degrees F. Freezer temperature maintained at 0 degrees F. LPA observed at least 2 days worth of perishables and 7 days worth of non-perishables food. LPA reviewed 4 resident and 4 staff files were maintained to include a medical assessment, TB result, appraisal/needs and services plan, safeguard of personal property and valuables, admission agreement, personal rights, and consent forms. 4 out of 4 residents centrally stored medications were reviewed. LPA observed that 4 out of 4 Centrally Stored Medication Record does not match the prescribed medications in the inventory. PRN medications were not written in the centrally stored medication record. LPA reviewed 4 staff records and 3 out of 4 staff record did not have the health screening record, 2 out of 4 did not have proof of TB test. 4 out of 4 staff record has fingerprint clearance and 1st aid certificate and updated training. LPA provided technical assistance to licensee and administrator for keeping accurate record of staff file and resident files and other corrections that needs to be addressed by the licensee and administrator. No deficiencies were cited during today's visit based on California Code of Regulations (CCR), Title 22. An exit interview was conducted with Licensee Rene Clemente and Administrator Aries Geronimo. A copy of the report was provided. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Jan 28, 2026

Type of visit: Collateral

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced collateral visit met with current licensee Rene Clemente. The purpose of the visit is to verify if the previous licensee - Perpetual Help Care Home #435294212 have conform to the agreement that transpired during transition of the ownership. The current licensee confirmed that the previous owner/licensee moved out of the facility on 09/14/2025 and received the official facility license on 09/15/2025. No citations were issued during today's visit and a copy of the report was provided to current licensee Rene Clemente. end of reportthe state’s words, verbatim · CDSS document, Sep 29, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Simi Rai arrived announced to conduct the facility's pre-licensing visit for change of ownership. LPA met with Applicant, Aries Geronimo and Rene Clemente. There are 4 residents present at the facility. This facility address is currently licensed. During visit, LPA toured the inside and outside of the facility to include the kitchen, dining, living room, garage, 3 resident rooms,and 2 bathrooms. Garage and second floor is off-limits. There is a locked shed in the backyard which is used for storage space and not a habitual space. All fire exit routes were free and clear of obstruction. Medication, chemicals, sharps and files have designated locked cabinets. Facility has an approved fire clearance for 6 non-ambulatory residents of which 1 may be bedridden in room #1 or room #3. The facility has a hospice care waiver for 2 residents. Bathrooms supplied with hygiene products and paper supplies. LPA observed the smoke and carbon monoxide detectors to be in working condition. The following posters observed to include the emergency telephone numbers, personal rights, and facility sketch. No issues noted during this pre-licensing inspection. COMP III was reviewed during visit. LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required. This report was reviewed with Applicant, Aries Geronimo and Rene Clemente. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 5, 2025

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of Ownership Capacity: 6 Census (if any clients in care): 5 COMP II Participants: ARIES GERONIMO, RENE CLEMENTE Interview Method: Telephone interview On June 03, 2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jun 3, 2025