Gracious Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Hernandez met with facility staff Narissa Geronimo. The capacity is (6) current census is (6). The facility is a six (6) bedroom, three (3) bathroom home with a kitchen/dining area, living room and attached garage. The facility is Residential Care Facility for the Elderly (RCFE). LPA Hernandez was accompanied by facility staff Narissa Geronimo to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 72 degrees. LPA Hernandez inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Hernandez observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCL complaint poster, were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine cabinet with the resident’s medications locked. LPA observed beside commode located in resident's bathroom to not be in good repair. Deficiency will be issued. Additionally, LPA observed Resident #4 (R4) has full bed rails and no hospice/doctor order. Deficiency will be issued. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision: The facility has sufficient number of staff to provide care and supervision to the residents in care. **Continuation on LIC809-C** Record Review: LPA Hernandez reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA observed no pre-admission appraisal for all Resident #1 (R1) and Resident #2 (R2) residents in care. Deficiency will be issued. LPA observed no updated/completed reappraisals for all (3) residents in care. Deficiency will be issued. Additionally, LPA observed no needs and services plan for all (3) residents in care. Deficiency will be issued. LPA observed three (3) residents medications. LPA observed Resident #2 (R2) PRN medication was not documented/administered correctly. Deficiency will be issued. LPA Hernandez reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) test result. No issues were observed. Based on the observations made during today’s visit, deficiencies were' cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Jesus Correa.the state’s words, verbatim · CDSS document, May 18, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Administrator Jesus Correa and was granted entry to the facility. At the time of the visit there was two (2) staff present, and six (6) residents present. The facility is a six (6) bedroom, three (3), bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (6) current census (6). LPA was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be 113 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside medication closet inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed six (6) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Jesus Correa.the state’s words, verbatim · CDSS document, Apr 7, 2025

Type of visit: Required - 1 Year

On 04/29/2024 at 11:00 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there was two (2) staff present, and five (5) residents present. House Manager Leofel Capulong and Administrator Paul Krause were contacted and arrived during the visit. LPA Brown explained the purpose of the visit to House Manager Leofel Capulong and Administrator Krause. The facility is a five (5) bedroom, three (3) bathroom home with a kitchen/dining area, living room, laundry area and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory residents of which one (1) may be bedridden. The facility has two (2) Hospice Waiver. The current census is five (5) residents. LPA Brown was accompanied by Staff #3 (S3) to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 78 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars but no non-skid mat in the resident shared bathroom. Deficiency will be issued. Also, LPA Brown observed Resident #2 (R2) with half bed rails and House Manager Leofel Capulong reported to LPA Brown that R2 does not have a written order from R2's Physician indicating the need of half bed rail for mobility. Deficiency will be issued. ***Continuation in LIC809C *** Moreover, during the tour of the facility, LPA Brown observed two (2) over the counter ointments in the kitchen drawer, not locked, accessible to residents in care. Deficiency will be issued. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 106 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster, Labor Laws and the Emergency Disaster plan were posted in a common area. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the hallway. LPA Brown observed no planned activities for the residents at the facility. Deficiency will be issued. Food Service: Seven (7) days non-perishable and three (3) days perishable food supplies were observed at the facility. LPA Brown observed that the facility has set Weekly Menu posted. Care & Supervision: The facility has an administrator present. LPA Brown observed that the facility have dementia residents per documents review and they do not have night supervision as there's no staff scheduled to work at night, awake and on duty. Administrator Krause confirmed that there's no staff assigned to work at night shift. Deficiency will be issued. Record Review: LPA Brown observed no Infection Control Plan at the facility. Deficiency will be issued. LPA reviewed three (3) resident files for admission agreements, updated physician reports, Preplacement Appraisal and Appraisal Needs and Services plans. LPA Brown observed Resident #1 (R1) Physician Report (LIC602) is incomplete as it's missing two (2) pages and without the Physician signature. Deficiency will be issued. Also, Resident #2 (R2) Preplacement Appraisal (LIC603) does not have Licensee/Administrator signature. Technical Violation issued. In addition, R2's Admission Agreement does not have Resident/Responsible Party and Licensee/Administrator Signature. Deficiency will be issued. Moreover, Resident #3 (R3) does not have updated Physician Report (LIC602) and per documents review, R3 has dementia and LPA Brown observed R3's physician signature date on 02/26/2020. Deficiency will be issued. Furthermore, LPA Brown observed that the Licensee/Administrator did not complete the required Needs and Services Plan for R1, R2 and R3. Deficiency will be issued. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA found that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) do not have completed Health Screening Report by their Physician. Deficiency will be issued. An exit interview was conducted where this report (LIC809), LIC809D, LIC9102 and Appeal Rights were discussed and provided to Narissa Geronimo and Administrator Paul Krause.the state’s words, verbatim · CDSS document, Apr 29, 2024

The state marks this report as 26 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.