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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 06:15:35 PM

Document Has Been Signed on 04/10/2024 06:15 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:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Emilissa Pangilinan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 4/10/2024 at 2:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a POC (proof of correction) inspection. LPA met with caregiver, Belen Catipon informed her the reason for the visit. Administrator, Emilissa Pangilinan arrived 30 minutes later.

The following deficiencies were cleared by visit:
- 80087(g); Staff locked up the oven cleaner, saw, and tree clipper during inspection on 3/28/2024.

- 80088(e)(1); Staff lowered hot water temperature and LPA re-measured hot water at 118.7 degrees F during inspection on 3/28/2024.

- 80010(b)(1); LPA received written plan via email on 3/29/2024.

- 80075(k)(1); LPA observed an unlocked insulin pen in the refrigerator during POC visit. Caregiver locked the insulin pen in the lockbox during visit. Civil penalty of $1200 is assessed for the period of 3/30/2024 to 4/10/2024 for failure to correct deficiency.


Exit interview conducted. A copy of this report, POC letters, civil penalties, 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)
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