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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200271
Report Date: 02/26/2025
Date Signed: 02/26/2025 02:49:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/20/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250220165447
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:
02/26/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Emillissa Pangilinan, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff left unlocked medications stored in plastic container with lid on the dining table
Staff left a large knife unlocked on the dining table
Staff did not have the key to open locked medication cabinet
INVESTIGATION FINDINGS:
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On 02/26/25 at 12:30PM, Licensing Program Analysts (LPAs) D Panlilio and P Manalo conducted an unannounced complaint visit, met with administrator (ADM), gathered information on the allegations and delivered investigation findings to ADM. LPAs explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from administrator – personnel record, clients’ roster, admission agreements, physicians reports, Needs & Services plans.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
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 7
Control Number 15-AS-20250220165447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271
VISIT DATE: 02/26/2025
NARRATIVE
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Allegation: Staff left unlocked medications stored in plastic container with lid on the dining table
Finding: Substantiated
During investigation, LPA interviewed staff (ADM, S1), clients (C1, C2, C3) and reviewed clients’ medication records. On 02/19/25, reporting party (RP) stated that he observed clients’ medications stored in small Tupperware containers inside a plastic bin with lid left unlocked/unattended on the dining table with two clients eating cereal in the same area. On 02/26/25 at 1PM, LPAs observed clients’ medications taken out of their original prescribed containers and re-stored in small Tupperware containers locked inside drawers. Review of facility records dated 04/10/24 showed the same deficiency was cited by LPA G Luk where clients’ medications were prepared by staff a week in advance and kept in a plastic container with lid. Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff left unlocked medications stored in plastic container with lid on the dining table. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated.

Immediate civil penalty of $250 assessed during visit for repeat violation of staff failing to ensure each clients’ medication is stored in its originally received container and inaccessible to clients in care.

Continued on next page, LIC9099-C pg2

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20250220165447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271
VISIT DATE: 02/26/2025
NARRATIVE
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Allegation: Staff left a large knife unlocked on the dining table
Finding: Substantiated
During investigation, LPA interviewed staff (S1) who stated they use the dining table in preparing meals for lunch and dinner. On 02/19/25, reporting party (RP) observed that staff left a large knife on the dining table unattended while two clients were eating cereal at the same area. During visit, LPAs observed S1 cutting vegetables with a large knife in the presence of a client sitting on the kitchen table. Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff left a large knife on the dining table unlocked and unattended. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated.

Allegation: Staff did not have the key to open locked medication cabinet
Finding: Substantiated
During investigation, LPA interviewed reporting party (RP) who stated that on 02/19/25 staff did not have the key code to open the locked medication cabinet at the facility. Staff (S1) confirmed with LPAs that she did have the key code to unlock the medication cabinet. However, the key code did not work when she tried to open the medication cabinet on 02/19/25 Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff did not have the key to open locked medication cabinet. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/20/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250220165447

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:
02/26/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Emillissa Pangilinan, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
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5
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9
Licensee is not ensuring that ratio requirements are being met
Staff are not ensuring that each client is accorded privacy while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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10
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13
On 02/26/25 at 12:30PM, Licensing Program Analysts (LPAs) D Panlilio and P Manalo conducted an unannounced complaint visit, met with administrator (ADM), gathered information on the allegations and delivered investigation findings to ADM. LPAs explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from administrator – personnel record, clients’ roster, admission agreements, physicians reports, Needs & Services plans.

Continued on next page, LIC 9099-C pg 3
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20250220165447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271
VISIT DATE: 02/26/2025
NARRATIVE
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Allegation: Licensee is not ensuring that ratio requirements are being met
Finding: Unsubstantiated
During investigation. LPAs interviewed staff (ADM, S1) who stated that they work at the facility Monday to Friday 8AM to 7PM and from 7PM to 8AM. All 6 ambulatory clients can leave the facility unassisted and three clients attend Adult Day Programs 2 to 3 times weekly. LPAs observed C1, C2, C3 as high functioning, independently doing their activities of daily living such as meals, medications/refills, doctors’ appointments, purchases, going to events. LPAs reviewed facility’s personnel record (LIC500) which showed two staff on duty Monday to Friday with night shift on call and two staff working Saturdays & Sundays. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that licensee is not ensuring that ratio requirements are being met was found to be unsubstantiated.

Allegation: Staff are not ensuring that each client is accorded privacy while in care
Finding: Unsubstantiated
During investigation. LPAs interviewed staff (ADM, S1) and random clients (C1, C2, C3). Review of clients’ needs and services plans showed they are ambulatory and require minimal assistance with personal hygiene such as toileting, grooming, dressing, bathing, medications and meals. Staff stated clients sometimes forget to close the toilet door in their rush to relieve themselves. Staff state they remind clients to close the toilet door whenever they use it but do not always do so. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not ensuring that each client is accorded privacy while in care was found to be unsubstantiated.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20250220165447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
Section Cited
CCR
80075(k)(5)
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Each client's medication shall be stored in its originally received container
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By POC due date, ADM agrees to submit completed staff in-service retraining on proper medication storage in compliance with Title 22 Section 80075 regulation.
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This requirement was not met as evidenced by clients’ medications stored in a plastic container with lid which is not the original container for each client’s medications and posed a potential health & safety risk to clients in care.
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Immediate civil penalty of $250 assessed for repeat violation on Section 80075(k)(5).
Type B
03/14/2025
Section Cited
CCR
80087(g)(1)
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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. Storage areas for poisons, and firearms and other dangerous weapons shall be locked
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By POC due date, ADM agrees to submit completed staff in-service retraining on ensuring all sharp objects are inaccessible to clients in care and be in compliance with Title 22 Section 80087 regulations
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This requirement was not met as evidenced by a large knife left unlocked and unattended to by staff which posed a potential health & safety risk to clients 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: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20250220165447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2025
Section Cited
CCR
85078(a)(1)
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The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs,
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Deficiency corrected during visit.
Faulty medication lock replaced to ensure staff can open medication cabinet effective 02/26/25
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This requirement was not met as evidenced by staff did not have the key to open the clients’ medication cabinet which posed a potential health & safety risk to clients 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: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7