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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006551
Report Date: 09/01/2026
Date Signed: 09/01/2026 05:04:03 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/01/2026 05:04 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GRACE SENIOR SOLUTIONS #2FACILITY NUMBER:
306006551
ADMINISTRATOR/
DIRECTOR:		GHAHYASI, JENIFERFACILITY TYPE:
740
ADDRESS:140 W. DUNTONTELEPHONE:
(714) 396-4321
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6CENSUS: 7DATE:
09/01/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Glenn Navarro, House ManagerTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. The Annual- Required was not provided for the report drop-down and a hard copy of the Care Tool was utilized during the visit. LPA was greeted and granted entry by Staff at 1pm. LPA met with House Manager, Glenn Navarro and explained the purpose of the visit.

The facility is a six bedroom, two bathroom residential home with an approved fire clearance for six non-ambulatory residents, in rooms 1-6, and one bedridden in Room #1 only. The facility is approved for a hospice waiver for six. Currently there are six residents and one additional tenant in bedroom #4 that receives care and three live-in staff members. There are three residents who receive hospice services.

During today's visit, LPA toured the facility and the facility was 74 degrees Fahrenheit. LPA tested and inspected carbon monoxide and smoke detectors and both detectors were operational. A fire extinguisher was charged and inspected on August 4, 2026 and is located by the front door. The last fire and earthquake drill was conducted on July 27, 2026.

LPA measured two of two bathroom hot water temperatures. The hot water temperatures ranged between 110.5 to 113.1 degrees Fahrenheit. Two of two bathrooms had non skid flooring, covered trash bins and grab bars in showers. LPA observed six resident rooms and all rooms were clean and had the required furnishings. Bedroom #1 is shared with two residents and the remaining bedrooms are single occupancy. Per interview, the tenant in Bedroom #4 receives assistance with showering, medications are centrally stored
(Continued on LIC 809-C)
Alisa Ortiz
RoseMarie Ruppert
DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE SENIOR SOLUTIONS #2
FACILITY NUMBER: 306006551
VISIT DATE: 09/01/2026
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(Continued from LIC 809)

and given to the resident at the prescribed time. The tenant also is served meals three times a day and is unable to cook their own meals. A family member lives nearby and provides transportation for medical services. Thus, the tenant is being provided care and supervision per Title 22 and the facility is over-capacity with seven residents. Additionally, the facility sketch documents that there is a two car garage but the area has been converted to an Additional Dwelling Unit for three of three staff members. A deficiency will be cited. An immediate $500 Civil Penalty will be assessed for fire clearance.

While touring resident bedrooms, LPA observed the resident in bedroom #3 had four half-rails on two sides of the bed. The resident is on hospice and had full bed rail orders. A deficiency will be cited for using four half-bed rails. The staff immediately removed all bed rails. LPA toured the kitchen and observed the facility has two days of perishable items and seven days of non perishable items. Appliances were in working order and emergency supplies were stored in the pantry. LPA observed medication storage and reviewed the centrally stored mediations. Per review medications are being given as prescribed.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on August 14, 2027.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Glenn Navarro, House Manager and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D, LIC 421IM and Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 09/01/2026 05:04 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 09/01/2026 at 03:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACE SENIOR SOLUTIONS #2
FACILITY NUMBER: 306006551

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2026
Section Cited
CCR
87202(a)

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a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by: Based on LPA observations and interviews, an additional tenant receives
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Administrator and House Manager will submit a plan of action regarding fire clearance, via email, to the Department by the POC due date.
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(cont'd) care and supervision and is considered a seventh resident. The facility is approved for six residents and is over capacity by an additional resident. This poses an immediate health and safety risk for persons in care.
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Type A
09/02/2026
Section Cited
CCR87608(a)(5)(B)

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(a) ... Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents
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Staff immediately removed the four bed raills during visit.
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(cont'd) who... have a hospice care plan that specifies the need for full bed rails. This requirement was not met as evidenced by. Based on LPA's observations the resident had four half rails. This poses an immediate health and safety risk for one of seven residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/01/2026 05:04 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 09/01/2026 at 03:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACE SENIOR SOLUTIONS #2
FACILITY NUMBER: 306006551

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2026
Section Cited
CCR
87305(a)

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Alterations to Existing Building or New Facilities. (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by: Based on LPA's observations and interviews, the two car garage was converted into an additional dwelling unit
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Administrator and House Manager will submit Plan of Action regarding additional dwelling unit, via email, to the Department by POC due date.
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(cont'd) with two staff bedrooms. The approved fire clearance with the Department shows this area is a garage. This poses an immediate health and safety risk for three of three persons residing in the garage.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2026


LIC809 (FAS) - (06/04)
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