019200271-1-23-2023-15-AS-LFII-CNCRUN-20230123122014

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200271
Report Date: 01/23/2023
Date Signed: 01/23/2023 12:21:05 PM

Document Has Been Signed on 01/23/2023 12:21 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	AMAZING GRACE CARE HOME		FACILITY NUMBER:	019200271
ADMINISTRATOR:	CORAZON PANGILINAN		FACILITY TYPE:	735
ADDRESS:	4617 MOWRY AVENUE		TELEPHONE:	(510) 565-1006
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY: 8		CENSUS: 7	DATE:	01/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Paulina Teca Joao- Administrator		TIME COMPLETED:	12:35 PM

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	On 1/23/2023, at 9:13 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an Annual Infection Control Visit. LPA was greeted by Paulina Teca Joao, Administrator (ADM) and explained the purpose of todays visit. During the inspection, LPA toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. All sharps and toxins were locked up and inaccessible to clients in care. Common areas are disinfected frequently throughout the day. Fire extinguisher was last serviced on 8/20/2021. Facilities room temperature is maintained at 68 Degrees F. First aid kit is complete. Carbon monoxide and smoke detectors are functional. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care. During record review, LPA observed facility has a copy of their Infection Control Plan and Disaster Plan on file. Continue on Lic809-C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/23/2023

NARRATIVE

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Continued from Lic809-C

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

1. At 9:20am, LPA observed a bottle of medication that belongs to C1 was left out on top of a table in the kitchen.

2. At 10:00am, LPA measure and observed water temperature at 139.5 in the clients common use bathroom.

Exit interview conducted with Administrator, appeal rights given, along with a copy of this report.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2023 12:21 PM - It Cannot Be Edited

Created By: Liridon Fici On 01/23/2023 at 11:54 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: 01/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not maintaining hot water temperature in clients common use bathroom which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2023
	Plan of Correction
1 2 3 4	Licensee agreed to check and maintain water temperature and to submit a photo to CCL by POC due date.

Type A

Section Cited

CCR

80075(k)(1)

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 responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not locking up medication in the locked cabinet; C1's bottle of medication was on a table in the kitchen accessible to client(s) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2023
	Plan of Correction
1 2 3 4	Licensee locked up the bottle of medication during visit. Deficiency cleared.

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:

Yvonne Flores-Larios

LICENSING EVALUATOR NAME:

Liridon Fici

LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

LIC809 (FAS) - (06/04)

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