Grace Seniors Care

Type of visit: Required - 1 Year

On 2/19/2026 at 12:10pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Yodit Gebreyohannes, Caregiver. Administrator, Filmon Woldemariam, arrived at 1:05pm, and LPA explained the purpose of the visit. Administrator holds a certificate #6070561740 expires 5/9/2026. The facility’s fire clearance was approved for five (5) non-ambulatory and 1 (one) bedridden resident. Facility has a hospice waiver for one (1). LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) bedrooms and three (3) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced 3/15/2025. Fire drill last conducted on 1/25/2026. Emergency Disaster Plan was last reviewed on 5/1/2025. First aid kit was observed to be complete. Continued on LIC809. Continued from LIC809C. LPA reviewed both resident and staff records, all were current and complete. LPA also reviewed medications. LPA requested the following documents to be submitted to CCLD by 2/26/2026. LIC308 Designation of Administrative Responsibility Liability insurance. LIC 500 Personnel Report LIC 610E Emergency Disaster Plan. (9 pages) Administrator certificate LPA observed the following deficiencies: At 12:30pm, LPA observed the facility did not have a 7-day supply or non-perishables and 2-day perishable foods. At 12:47pm, LPA observed laundry room turned into staff room. At 12:55pm, LPA observed R1 and R2 having half bed rails with no doctor orders. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report providedthe state’s words, verbatim · CDSS document, Feb 19, 2026

Type of visit: Case Management - Other

On 02/11/2025 at 10:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived announced to amend report previously issued on 02/06/2025. LPA met with Licensee, Filmon Yemane Gebrekidan/Administrator, Filmon Berhe Woldemariam LPA T. Syess-Gibson amended report (LIC809) previously issued on 02/06/2025. LPA printed the amended reports and provided a copy to Licensee, Filmon Yemane Gebrekidan/Administrator, Filmon Berhe Woldemariam Exit interview conducted. A copy of the reports was provided.the state’s words, verbatim · CDSS document, Feb 11, 2025

Type of visit: Prelicensing

***THIS IS AN AMENDMENT OF PRE-LICENSING REPORT DATED 02/06/2025.*** On 02/06/2025 at 10:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrive announced to conduct a Pre-licensing Inspection to verify corrections were made from visit on 01/28/2025. LPA met with Licensee, Filmon Yemane Gebrekidan/Administrator, Filmon Berhe Woldemariam. The facility’s fire clearance was approved for five (5) non ambulatory and one (1) bedridden resident. LPA toured facility but not limited to resident's bedrooms, bathrooms, living room, kitchen, and outdoor area. LPA observed all six (6) beds in residents’ rooms have blankets, bedspreads, top bed sheets, mattress pads and bedroom #1 to be complete with bed, chair and chest of drawers. LPA also observed signal system in kitchen and call buttons in residents’ rooms. LPA measured hot water at 109.2 degrees F. LPA observed paper towel with paper towel holders and night lights in residents shared bathroom. LPA observed facility does have resident rights/information -20"x 26" PUB 475 poster posted in entry of facility. LPA observed delivery date for outdoor table with umbrella is scheduled to arrive today on 02/06/2025. LPA observed mechanical lock in the backyard was removed and replaced. LPA conducted COMP III with Licensee and Administrator during visit. Continue LIC809C Continued from LIC809 The licensee/administrator was reminded of the statute that requires CCL to be notified within 5 business days of admitting their first resident. This notification may be done by phone, by mail, or by fax. No Issues were noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 6, 2025

Type of visit: Prelicensing

On 01/28/2025 at 10:15AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted a Pre-licensing Inspection. LPA met with Licensee, Filmon Yemane Gebrekidan/Administrator, Filmon Berhe Woldemariam LPA toured facility including but not limited to resident's bedrooms, bathrooms, living room, dining area, kitchen, garage, and outdoor area. LPA observed lighting in all rooms. LPA observed facility had some non-perishable food supply. Licensee will purchase additional food supplies once facility is licensed. Carbon monoxide and smoke detectors was observed in operating condition. First aid kit was complete. Emergency disaster plan was complete. Fire Extinguisher last serviced on 03/08/2024. LPA will conduct the Comp III presentation on next visit. The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB): 1. LPA observed Hot water was measured at 140.1 degrees F in the shared bathroom sink. 2. LPA observed the common bathrooms does not have paper towel holders. 3. LPA observed common bathrooms does not have night lights available. 4. LPA observed bedroom #1 is missing a bed, chair and chest of drawers. Continue on LIC809C Continued from LIC809 5. LPA observed all six (6) beds in residents rooms does not have blankets, bedspreads, top bed sheets and mattress pads. 6. LPA observed facility does not have signal system. 7. LPA observed facility does not have Resident Rights/Information -20"x 26" PUB 475 poster 8. LPA observed Outdoor activity areas that are easily accessible to residents, does not have adequate shady area for residents. Licensee/Administrator has ordered table with umbrella. 9. LPA observed back gate has a mechanical lock and facility does not have a fire clearance with locked perimeter. LPA requested licensee to either obtain property fire clearance or remove the mechanical lock on back gate. Licensee/Administrator agreed to remove the lock. Licensee/Applicant will make the corrections before 2/6/2025. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 28, 2025

The state marks this report as 9 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for the Elderly (RCFE) Application Type: Initial Capacity: 6 Census (if any clients in care): none COMP II Participants: Filmon Woldermariam, Administrator/Applicant Filmon Gebrekidan, Applicant Interview Method: Telephone interview On December 10, 2024, Applicants and Administrator participated in COMP II. Identification of the Applicants and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB analyst confirmed Applicants and Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Applicants and Administrator. Report sent via email and informed to return sign copy to CAB by end of business day today.the state’s words, verbatim · CDSS document, Dec 10, 2024