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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200271
Report Date: 10/06/2022
Date Signed: 10/06/2022 12:06:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220412164404
FACILITY NAME:AMAZING GRACE CARE HOMEFACILITY NUMBER:
019200271
ADMINISTRATOR:CORAZON PANGILINANFACILITY TYPE:
735
ADDRESS:4617 MOWRY AVENUETELEPHONE:
(510) 565-1006
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:8CENSUS: 8DATE:
10/06/2022
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Paulina Teca Joao, StaffTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff left resident's unattended
Staff did not prevent resident from engaging in inappropriate behaviors
INVESTIGATION FINDINGS:
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On 10/6/22 at 8:50am, Licensing Program Analysts (LPAs) C. Lin and L. Fici arrived unannounced a subsequent complaint visit to investigate the above allegation. LPAs met with staff and informed her the purpose of visit. Administrator Emillissa Pangilinan arrived at a later time.

Allegation: Staff left resident’s unattended – Substantiated
The Department has investigated this allegation and per records review and interviews and found that no staff supervised clients at NOC shift was occurred occasionally. 1 staff (S1) and 4 clients (R2, R4, R5 and R6) had witnessed that no staff stayed in the facility 3-4 times in subject time period.

Continue LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20220412164404
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271
VISIT DATE: 10/06/2022
NARRATIVE
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Allegation: Staff did not prevent resident from engaging in inappropriate behaviors – Substantiated
The Department has investigated this allegation and observations and interviews and found that no staff supervised clients at facility when 911 call was made by client (R1) in subject time period. Clients (R5 and R6) had witnessed that client (R4) answered call from 911 dispatcher due to no staff at facility.

Based on information obtained, the preponderance of evidence is met, therefore the allegations are substantiated.

Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. A immediate $500 civil penalty is assessed on this day.

Deficiencies and plan and proof of correction were discussed with the Administrator.

Exit interview conducted with Administrator, LIC9099D, Appeal Rights, and copy this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220412164404

FACILITY NAME:AMAZING GRACE CARE HOMEFACILITY NUMBER:
019200271
ADMINISTRATOR:CORAZON PANGILINANFACILITY TYPE:
735
ADDRESS:4617 MOWRY AVENUETELEPHONE:
(510) 565-1006
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:8CENSUS: 8DATE:
10/06/2022
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Paulina Teca Joao, StaffTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident is administering medications to other resident's
Resident is providing care to other resident's
INVESTIGATION FINDINGS:
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Allegation: Resident is administering medications to other resident’s – Unsubstantiated
The Department has investigated this allegation and per records review and interviews and found that staff and clients denied medication was given by another client.

Allegation: Resident is providing care to other resident’s – Unsubstantiated
The Department has investigated this allegation and per records review and interviews and found that facility staff denied asking client to provide care to others. 7 Clients have not witnessed that care was provided by another client.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Administrator, and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20220412164404
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2022
Section Cited
CCR
85065.6
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85065.6 Night Supervision
(c) In facilities providing care and supervision for 15 or fewer clients, there shall be at least one person on call on the premises.

This requirement is not met as evidenced by…
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Administrator agrees to review regulation and submit a self-certification of understanding regulation to CCL by the POC due date.
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Based on observation and interview the licensee did not comply with the section cited above. LPAs observed absence of supervision at NOC shift was occurred 3-4 times which poses an immediate health, safety or personal rights risk to persons in care.
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A $500 immediate civil penalty is assessed today.
Type B
10/13/2022
Section Cited
CCR
85065(b)
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85065 Personnel Requirements
(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

This requirement is not met as evidenced by…
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Administrator agrees to review regulation and provide in-service training to staff, submit a self-certification of understanding regulation and proof of training with staff signature to CCL by the POC due date.
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Based on observation the licensee did not comply with the section cited above. LPAs observed that client’s behavior was not supervised by staff in subject time period which posed an potential health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4