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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200271
Report Date: 03/21/2025
Date Signed: 03/21/2025 05:13:31 PM

Document Has Been Signed on 03/21/2025 05:13 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
OAKLAND ASC, 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: 7DATE:
03/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Emilissa Pangilinan, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 03/21/2025 at 11:05 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Emilissa Pangilina, and explained the purpose of the visit. Administrator certificate is current and expires 09/24/2026. The facility’s fire clearance was approved for eight (8) ambulatory only.

LPA toured the facility including inside and out but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. There are no bodies of water. A comfortable temperature for clients is maintained at 68 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 112.3 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/03/2025. Emergency Drill was last conducted on 03/07/2025.

At 12:49 PM, 5 of clients records were reviewed. At 1:19 PM, 3 staff records were reviewed and are associated to the facility. LPA reviewed 3 sample of client's medications.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AMAZING GRACE CARE HOME
FACILITY NUMBER: 019200271
VISIT DATE: 03/21/2025
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Continue from LIC809-C...

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • At 11:30 AM, LPA observed camera and audio in the kitchen, living room, and hallway areas. Administrator stated that the camera feed has audio.
  • At 11:45, LPA observed having laundry detergent out in the garage accessible to clients' in care. Immediate civil penalty of $250 assessed for repeat violation.
  • At 12:13 PM, LPA observed that C1, C3, and C4's prescription medications not available for review but is on the Medication Administration Record (MAR). Immediate civil penalty of $250 assessed for repeat violation.
  • At 12:30 PM, during record review, LPA observed not having a LIC 503 Health Screening for S2 and S3. Immediate civil penalty of $250 assessed for repeat violation.
  • At 1:15, LPA observed that C3 and C4 are non-ambulatory and the facility is only approved for ambulatory. Immediate Civil Penalty of $500 assessed.
  • At 3:15 PM, during record review, LPA observed that there are three clients over the age of 60.
  • At 3:30 PM, LPA observed that dementia diagnosis for C3.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
LIC809 (FAS) - (06/04)
Page: 2 of 14
Document Has Been Signed on 03/21/2025 05:13 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/21/2025 at 02:35 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: 03/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation, the licensee did not comply with the section cited above in having laundry detergent out in the garage accessible to clients' in care which poses an immediate health and safety risk to persons in care.

Immediate civil penalty of $250 assessed for repeat violation.
POC Due Date: 03/22/2025
Plan of Correction
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2
3
4
Administrator agrees to lock the laundry detergent and send proof to CCLD by POC date.
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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 having C3 and C4 who is non-ambulatory and the facility is not approved for non-ambulatory which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/22/2025
Plan of Correction
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Within 24 hours, the Administrator will notify the local fire department about the non-ambulatory clients, obtain a new Physican's Report for both clients within 30 days, and send proof to CCLD.

Immediate $500 civil penalty assessed.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


LIC809 (FAS) - (06/04)
Page: 3 of 14
Document Has Been Signed on 03/21/2025 05:13 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/21/2025 at 02:35 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: 03/21/2025

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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3
4
Based on record review, the licensee did not comply with the section cited above by not having a LIC 503 Health Screening for S2 and S3 which poses a potential health and safety risk to persons in care.
POC Due Date: 04/07/2025
Plan of Correction
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Administrator agrees to obtain a LIC 503 Health Screening for both staff and send proof to CCLD by POC date.

Immediate civil penalty of $250 assessed for repeat violation.
Type B
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 and record review, the licensee did not comply with the section cited above by not having C1, C3, and C4's prescription medications in the facility but is on the Medication Administration Record (MAR) which poses a potential health and safety risk to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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Administrator agrees to contact the pharmacy and clients' physician to obtain a discontinued order, and send proof to CCLD by POC date.

Immediate civil penalty of $250 assessed for repeat violation.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 03/21/2025 05:13 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/21/2025 at 03:11 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: 03/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in camera and audio in the kitchen, living room, and hallway areas which poses a potential health and safety or personal risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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Administrator agrees to obtain consent from family/ clients', turn off audio, and send proof to CCLD by POC date.
Type B
Section Cited
CCR
85068.4(g)
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.

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 in having three clients over the age of 60 which poses a potential health and safety risk to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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Administrator agrees to obtain an age exception request and send 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


LIC809 (FAS) - (06/04)
Page: 12 of 14
Document Has Been Signed on 03/21/2025 05:13 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/21/2025 at 03:43 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: 03/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(a)(4)
(a) The licensee shall not accept or retain the following:
(4) Persons who require more care and supervision than is provided by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above by having a dementia diagnosis for C3 which poses a potential health and safety risk to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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2
3
4
Administrator agrees to obtain a new Physician's Report for C3 and send proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


LIC809 (FAS) - (06/04)
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