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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200271
Report Date: 10/06/2022
Date Signed: 10/06/2022 12:10:58 PM

Document Has Been Signed on 10/06/2022 12:10 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Emillissa Pangilinan, AdministratorTIME COMPLETED:
12:25 PM
NARRATIVE
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On 10/6/22, Licensing Program Analysts (LPAs) C. Lin and L. Fici conducted case management, met with Administrator, and explained the purpose of visit.

During the course of investigation on a complaint, the Department observed packs of unlocked medication were on the top of medication cabinet and inside the cabinet. Staff locked up medication during visit. This is a repeating violation cited on 4/21/22. A $250 repeating violation civil penalty is assessed on this day.

Deficiency is cited per Title 22 California Code of Regulations. Please refer to LIC 809D.

Exit interview was conducted with Administrator, LIC809D, Appeal Rights, and a copy of 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/06/2022 12:10 PM - It Cannot Be Edited


Created By: Catherine Lin On 10/06/2022 at 11:18 AM
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
, 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
80075(k)(1)

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80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees....
This requirement is not met as evidenced by:
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Staff locked up medication during visit.
In addition, Administrator agrees to retrain staff for the regulations and submit training agenda with staff signatures to CCL by the POC due day.
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Based on observation, the licensee did not comply with the section cited above, where medication was accessible to clients which poses an immediate 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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