<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200271
Report Date: 08/21/2025
Date Signed: 08/21/2025 03:20:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
08/15/2025 and conducted by Evaluator Patricia Manalo
COMPLAINT CONTROL NUMBER: 15-AS-20250815090718
FACILITY NAME:AMAZING GRACE CARE HOMEFACILITY NUMBER:
019200271
ADMINISTRATOR:EMILISSA PANGILINAFACILITY TYPE:
735
ADDRESS:4617 MOWRY AVENUETELEPHONE:
(510) 418-9027
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:8CENSUS: 7DATE:
08/21/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Emilissa Pangilina, Administrator TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee is utilizing inappropriate house rules with residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/21/2025 at 9:40 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct a complaint investigation and deliver findings on the above allegation. LPA met with Administrator Emilissa Pangilina and explained the purpose of the visit.

During the course of investigation, LPA interviewed the Administrator (ADM) and six (6) clients.

LPA reviewed and obtained documents including but not limited to residents’ Admission Agreement, Facility’s Photo Release Form, Admission Agreement Memorandum, and Amazing Grace Independent Living House Rules.

Continue to LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
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 3
Control Number 15-AS-20250815090718
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/21/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continue from LIC9099...

It was alleged that licensee is utilizing inappropriate house rules with residents in care. 6 of 7 clients that were interviewed all stated that the house rules are okay and don’t make them feel uncomfortable. However, based on a record review of the Admission Agreement Memorandum and the Amazing Grace Independent Living House Rules, LPA observed and confirmed that these rules are violating clients’ personal rights.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250815090718
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/04/2025
Section Cited
CCR
80072(a)
1
2
3
4
5
6
7
80072(a) Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator agrees to revise the facility’s house rule and send it to CCLD for review by POC date.
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not comply with the section cited above. LPA reviewed the Admission Agreement Memorandum and the House rules including but not limited to visitation, kitchen hours, lights, transportation, telephone rules, etc., which poses potential personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3