Grace Home Bachelor Peak

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Administrator Jennifer Hahn. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, of whom all may be bedridden. Hospice waiver for six (6). During today’s inspection there were five (5) residents in care. LPA with staff toured the interior and exterior of the facility and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. LPA observed medications that were transferred into unlabeled containers for five (5) residents. The medications had been transferred from their originally received containers. No pools or bodies of water exist on the premises. Per Administrator Jennifer Hahn, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, fire extinguisher, and facility telephone were all in working order. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. One deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A plan of correction was jointly formulated, and an exit interview was conducted with Administrator Hahn, to whom a copy of this report, LIC809-C, LIC809-D and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Oct 29, 2025

Type of visit: Prelicensing

On 11/07/2024 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility for the purpose of a Prelicensing Visit. LPA met with Applicant/Administrator Jennifer Hahn. An initial application for license to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 03/05/2024 for a total capacity of six (6). Fire clearance was granted on 07/30/2024 for six (6) bedridden. LPA Brown observed the following: Structure: Facility's a one (1) level house with six (6) bedrooms; five (5) bedrooms for residents and one (1) staff bedroom, three (3) resident/staff bathrooms, living room, dining area, laundry room and kitchen. There is an attached two (2) car garage. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control the entire house. Bedrooms: Each resident bedrooms accommodate any bedridden resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, lamps, adequate lighting, and an operable combined smoke and carbon monoxide alarm. Bathrooms: The three (3) staff/resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. LPA Brown tested the water temperature in the resident/staff bathrooms. LPA verified water temperature was measured at 111.12 degrees Fahrenheit. ***CONTINUED ON LIC 809C*** ***CONTINUED FROM LIC 809*** Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. Applicant/Administrator Hahn reported that they will have more than seven (7) days’ supply of non-perishable foods and more than two (2) days’ supply of perishable foods. There’s an adequate seating for meals for all residents. Laundry room with washer and dryer. Laundry detergents and cleaning supplies are stored in the laundry room that will not be accessible to residents. Living/Family room: There’s a living/family room with adequate seating for all residents and a working TV. Linens and Hygiene Supplies: An adequate supply of linens was stored in each resident closet. Yards/Outside: Patio furniture for outdoor seating observed. Side Gate on the left side of the facility. All outdoor pathways were free of obstructions. Emergency Phone Numbers, and Exit Plan: Facility sketch was observed posted in the living/family room hallway. Ombudsman poster, Let-Us-No poster, Personal Rights, Emergency Disaster Plan, Rights to Resident Council, Personal Property/Theft and Loss and Labor Laws were observed. Dementia Care Plan: LPA Brown observed and reviewed the Dementia Care Plan during the visit. General items: One (1) fire extinguisher was charged and located in the hallway of the facility. Dual smoke alarms and carbon monoxide detectors were tested and were observed to be in working order. Resident records will be stored in a locked cabinet in the living/family room hallway. First Aid kit with required components, First Aid book and locked cabinet for medication storage was observed. LPA Brown observed a facility phone and was operational as evidenced of LPA dialing the number. The phone number designated for the facility is 951-599-0088. There is enough Emergency water supply observed and the required 72-hour emergency food supply were observed from the regular food supply. ***CONTINUED ON LIC 809C*** ***CONTINUED FROM LIC 809C** Component III was completed on this day as well. LPA Brown observed activities for the residents such as books and games. Additionally, upon entry, LPA Brown observed the facility having Visitor Sign In/Sign Out Sheet and Resident Sign In/Sign Out Sheet. The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, to ensure the health and safety of residents in care. Applicant/Administrator Hahn has satisfied all requirements in accordance with Title 22, California Code of Regulations. Facility appears to be ready for licensure. An exit interview was conducted, and a copy of this report, LIC809 was discussed, reviewed and provided to Applicant/Administrator Jennifer Hahn.the state’s words, verbatim · CDSS document, Nov 7, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Method: Telephone call with CAB COMP II Participants: Hahn, Jennifer On 10/1/24, the applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. 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. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Oct 1, 2024