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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200271
Report Date: 04/10/2024
Date Signed: 04/10/2024 06:21:08 PM

Document Has Been Signed on 04/10/2024 06:21 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 HOMEFACILITY NUMBER:
019200271
ADMINISTRATOR/
DIRECTOR:		CORAZON PANGILINANFACILITY TYPE:
735
ADDRESS:4617 MOWRY AVENUETELEPHONE:
(510) 565-1006
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 8CENSUS: 8DATE:
04/10/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Emilissa Pangilinan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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On 4/10/2024 at 2:45PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management - Annual Continuation. LPA met with Administrator, Emilissa Pangilinan and explained the reason for the visit.

During visit, LPA interviewed 3 clients and 2 staff starting at 3:30PM. At around 4:10PM, LPA reviewed a sample of client's' medications with their centrally stored records and MAR (Medication Administration Records).

At 3:00PM, LPA observed S1 and S2 does not have health screening on file.

At 3:05PM, LPA observed S1 and S2 does not have TB test results on file.

At 3:10PM, LPA observed C1 does not have current IPP or needs and service plan on file.

At 4:10PM, LPA observed client's medications are prepared a week in advance and placed in weekly containers for each clients. The medications were out of its originally received container.

At 4:40PM, LPA observed C1 ran out of Amlodipine 2.5mg and facility does not have medication available.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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 7
Document Has Been Signed on 04/10/2024 06:21 PM - It Cannot Be Edited


Created By: Grace Luk On 04/10/2024 at 05:15 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: 04/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

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 prescription medication available for C1 which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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Administrator has agreed to obtain refill for Amlodipine for C1 and submit picture proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 04/10/2024 06:21 PM - It Cannot Be Edited


Created By: Grace Luk On 04/10/2024 at 05:15 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: 04/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

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 health screening for S1 and S2 which poses a potential health and safety risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Administrator has agreed to obtain health screening for S1 and S2 and submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

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 TB test results for S1 and S2 which poses a potential health and safety risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Administrator has agreed to obtain TB test results for S1 and S2 and submit a copy 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/10/2024 06:21 PM - It Cannot Be Edited


Created By: Grace Luk On 04/10/2024 at 05:15 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: 04/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(5)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (5) Each client's medication shall be stored in its originally received container.

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 preparing medications a week in advance which poses a potential health and safety risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Administrator has agreed to conduct medication training for all staff and submit staff sign in sheet to CCLD by POC date.
Type B
Section Cited
CCR
80068.2(b)(1)
(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that:
(1) The needs appraisal or IPP is not more than one year old.
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 current needs and service plan for C1 which poses a potential health and safety risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Administrator has agreed to obtain current needs and service plan for C1 and submit a copy 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
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