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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200271
Report Date: 03/12/2026
Date Signed: 03/12/2026 02:22:50 PM

Document Has Been Signed on 03/12/2026 02:22 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AMAZING GRACE CARE HOMEFACILITY NUMBER:
019200271
ADMINISTRATOR/
DIRECTOR:		EMILISSA PANGILINAFACILITY TYPE:
735
ADDRESS:4617 MOWRY AVENUETELEPHONE:
(510) 418-9027
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 8CENSUS: 8DATE:
03/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Emilissa Panglina, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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On 03/12/2026 at 9:00 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator Emilissa Panglina and explained the purpose of the visit. Administrator certificate is current.

LPA toured the facility including inside and out but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 bedrooms in total, of which 4 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degree Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 100 degree Fahrenheit. The supply of extra hygiene's was available for clients.

Smoke detectors and carbon monoxide were in operating condition during visit. First aid kit was observed to be complete. Fire drill was last conducted on 03/03/2026.

At 9:53 AM, 5 of clients’ records were reviewed. At 10:33 AM, 3 staff records were reviewed and 2 of 3 have current first aid training and 3 of 3 associated with the facility. LPA reviewed client's P&I money with log. LPA reviewed two samples of clients’ medications.


Continue to LIC809-C…
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2026
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 15
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)
Page: 2 of 15
Document Has Been Signed on 03/12/2026 02:22 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/12/2026 at 12:32 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having the smoke alarm not installed in C2, C6, C7, and C8's room and the backyard fence leaning into the neighbor's side yard which poses a potential safety risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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By POC date, the Administrator agrees to install the fire alarms and fix the backyard fence. Proof of correction will be sent to CCLD.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having the hot water temperature measured up to 100 degrees Fahrenheit and the water temperature kept lowering which poses a potential health and safety risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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By POC date, the Administrator agrees to have the hot water temperature measured within range and send proof to CCLD.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2026


LIC809 (FAS) - (06/04)
Page: 3 of 15
Document Has Been Signed on 03/12/2026 02:22 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/12/2026 at 12:32 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85065.5(a)(2)
Day Staff-Client Ratio
(2) For all other clients, there shall be a staff-client ratio of no less than one direct care staff to three such clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and observation, the licensee did not comply with the section cited above by only having 1 staff on shift with 7 clients in the facility which posed a potential safety risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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By POC date, the Administrator agrees to self certify the regulation and send an updated LIC500 to CCLD.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a TB test result on file for C1 which poses a potential health risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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By POC date, the Administrator agrees to obtain a TB test result for C1 and send proof to CCLD.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2026


LIC809 (FAS) - (06/04)
Page: 4 of 15
Document Has Been Signed on 03/12/2026 02:22 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/12/2026 at 12:32 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(10)
Client Records
(b) Each record must contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a doctor's order for C1 and C2's PRN medication which poses a potential health and safety risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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By POC date, the Administrator agrees to have the doctor's order for C1 and C2's PRN medication and send proof to CCLD.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having sufficient nonperishable and perishable food for all the clients in care which poses a potential health and safety risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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By POC date, the Administrator agrees to purchase more food items and send proof to CCLD.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2026


LIC809 (FAS) - (06/04)
Page: 5 of 15
Document Has Been Signed on 03/12/2026 02:22 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/12/2026 at 12:42 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(b)
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not submitting an incident report or reporting to licensing that C5 is in the hospital which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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By POC date, the Administrator agrees to submit an incident report to licensing and self-certify the regulation. Proof of correction will be sent to CCLD.
Type B
Section Cited
CCR
80075(f)
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a First Aid certification for S3 which poses a potential health and safety risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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By POC date, the Administrator agrees to self-certify the regulation and obtain a First Aid certification for S3. Proof of correction will be sent to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2026


LIC809 (FAS) - (06/04)
Page: 9 of 15
Document Has Been Signed on 03/12/2026 02:22 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/12/2026 at 12:52 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with having unlocked Ciclopirox Cream and Melatonin in C1’s and C5’s room and Halobetasol Ointment and Triamcinolone Acetonide Ointment in C6’s and C7’s room which poses an immediate safety risk to persons in care. In addition, LPA observed landscaping tools in the backyard such as a mallet and shovel which poses an immediate safety risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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By POC date, the Administrator agrees to lock the items and send proof to CCLD.
Type A
Section Cited
CCR
80020(a)
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having the fire extinguisher serviced which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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By POC date, the Administrator agrees to service the fire extinguisher and send proof to CCLD.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2026


LIC809 (FAS) - (06/04)
Page: 10 of 15
Document Has Been Signed on 03/12/2026 02:22 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/12/2026 at 12:54 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above by not having a completed record for clients' Medication Administration Record (MAR), C5's file, and C3's P&I log. LPA also observed that C3's P&I is not maintained in the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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2
3
4
By POC date, the Administrator agrees to have an in-service for the MAR to ensure that documentation is maintained, complete C5's file, and complete C3's P&I log. LPA will verify that the p&I money and log is in the facility. Proof of correction will be sent to CCLD by POC date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2026


LIC809 (FAS) - (06/04)
Page: 11 of 15
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271
VISIT DATE: 03/12/2026
NARRATIVE
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Continued from LIC809…

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/20/2026:

LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:10 AM, LPA observed 1 staff with 7 clients all at home. Repeat Civil Penalty of $250 is assessed.

At 9:15 AM, LPA observed Ciclopirox Cream and Melatonin in C1’s and C5’s room and Halobetasol Ointment and Triamcinolone Acetonide Ointment in C6’s and C7’s room which poses an immediate safety risk to persons in care. In addition, LPA observed landscaping tools in the backyard such as a mallet and shovel. Repeat Civil Penalty of $250 is assessed.

At 9:21 AM, LPA observe the fire extinguisher was last serviced on 03/03/2026. Repeat Civil Penalty of $250 is assessed.

At 9:30 AM, LPA observed the hot water temperature measured at 100 degrees Fahrenheit and the water temperature kept lowering.

At 9:45 AM, record review and interview revealed that the facility did not follow the reporting requirements when C5 went to the hospital.

At 10:00 AM, LPA observed that S3 does not have first aid certification on file.

Continue to LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC809 (FAS) - (06/04)
Page: 14 of 15
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271
VISIT DATE: 03/12/2026
NARRATIVE
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3
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5
6
7
8
9
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32
Continued from LIC809-C...

At 11:10 AM, LPA observed the smoke alarm not installed in C2, C6, C7, and C8's room and the backyard fence leaning into the neighbor's side yard.

At 11:51 AM, LPA observed that the facility did not have enough perishable and nonperishable food for 8 clients.

At 12:00 PM, LPA observed that C1 and C2 do not have a doctor's order for their PRN medications.

At 12:13 PM, LPA observed that C1 does not have a TB test result on file.

At 12:26 PM, record review revealed that the record for clients' Medication Administration Record (MAR), C5's file, and C3's P&I log is incomplete. LPA also observed that C3’s P&I is not maintained in the facility.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights, LIC421FC, and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC809 (FAS) - (06/04)
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