197604814-7-2-2025-31-AS-NGID-DJZU32-20250728151247

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197604814
Report Date: 07/02/2025
Date Signed: 07/02/2025 02:19:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/05/2025 and conducted by Evaluator Leslie Ngo-Castaneda

COMPLAINT CONTROL NUMBER: 31-AS-20250305082603

FACILITY NAME:	AMAZING GRACE HOME CENTER		FACILITY NUMBER:	197604814
ADMINISTRATOR:	GRACE O. BAJOMO		FACILITY TYPE:	735
ADDRESS:	8732 DEBRA AVENUE		TELEPHONE:	(818) 895-6332
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	4	CENSUS: 3	DATE:	07/02/2025
		UNANNOUNCED	TIME BEGAN:	01:09 PM
MET WITH:	GRACE O. BAJOMO- Licensee		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care.
Staff did not medical attention to resident.
Staff does not transport resident to medical appointments.
Staff does not ensure resident is adequately fed resulting weight loss.
Staff does not communicate with resident's responsible party.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted a subsequent complaint visit to the facility to investigate the above allegations. LPA met with the licensee, Grace Bajomo, and advised her about the visit. At 1:30PM, LPA conducted a physical plant tour to ensure the health and safety of the clients in care.

An entrance interview was conducted.

Allegation #1: Resident sustained an unexplained injury while in care.

It was alleged that Client#1 (C1) was observed with a missing nail on their left hand and possible fungus infection. To investigate the allegation initial ten-day visit was conducted on 3.11.2025 by LPA Ngo-Castaneda.
Continue to LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250305082603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMAZING GRACE HOME CENTER	FACILITY NUMBER: 197604814
	VISIT DATE: 07/02/2025

NARRATIVE

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At 2:00 PM, LPA conducted a physical plant tour to ensure the health and safety of the clients are protected. Between 1:30 PM to 3:30 PM, LPA reviewed files which include, but not limited to staff roster; resident roster, C1 physician’s report, admissions agreement, IPP, facility menu, and other documents. LPA interviewed two (2) out of two (2) clients who are non-verbal and four (4) staff. At the time of the visit, LPA obtained a copy of the staff and resident roster and requested residents’ files at 2:30 PM.

Staff interview revealed that C1's behavior had caused their fingernail to be ‘very red’ as part of their behavior. On 5.19.2025 LPA reviewed medical records dated 3.3.2025 from Northridge Hospital. Records revealed because of C1 constant movement, 'subungual hematoma, of the fingernail' occurred. Staff brought C1 to seek medical attention on 3.03.2025. Based on interviews and documentation review, there is insufficient evidence to verify when and how the injuries occurred.

There is no corroborating information/evidence to concur that C1 was injured while in care at the facility. Therefore, the allegation above noted is deemed UNSUBSTANTIATED at this time.

Allegation #2: Staff did not provide medical attention to the resident.

It was alleged that staff did not ensure that the client was provided adequate medical attention. To investigate this allegation on 3.11.21025, between 1:30 PM to 3:30 PM, staff interviews were done. Interviews revealed that staff took C1 to seek medical attention on 3.3.2025 when they noticed that C1's finger was very red. Incident report was checked and received from the facility.

Based on interviews, there is not sufficient information to support the allegation. Thus, the allegation is UNSUBSTANTIATED at this time.

Allegation #3: Staff does not transport residents to medical appointments.

Regarding the allegation, it was reported that there is no transportation to take the clients to their medical appointments on 3.3.2025. Interviews with four (4) staff members state that transportation is made by the facility van. The facility van was inoperable, staff set up a ride with Lyft for C1 to see a physician. LPA requested S1 to show Lyft receipt and LPA obtained a copy of receipt.
Continue to LIC 9099-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20250305082603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMAZING GRACE HOME CENTER	FACILITY NUMBER: 197604814
	VISIT DATE: 07/02/2025

NARRATIVE

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Based on the information obtained during the interview, there was not enough evidence to prove that transportation was not provided to the clients. Therefore, the allegation is deemed Unsubstantiated at this time.

Allegation #4: Staff does not ensure the resident is adequately fed, resulting in weight loss.

LPA Ngo-Castaneda interviewed four (4) staff members who were working at the time C1 was a client. All four (4) staff members confirmed that they did not witness R1 losing an extreme amount of weight. Staff members stated they had witnessed C1 eating a healthy amount of food and would request a second plate sometimes. Staff members also stated there is an adequate supply of food for the clients, and have never witnessed a client stating they were hungry and did not have enough food to eat. LPA attempted to interview two (2) clients who are non-verbal, clients gave LPA a thumbs-up and smiles. LPA observed the kitchen and refrigerator to be full and abundant. Facility menu was posted in the kitchen bulletin board. You need to include the files you reviewed and your analysis to determine that C1 did not have weight loss.

Based on the information and observation obtained during the visit, there was not enough evidence to prove that there is no staff to ensure the clients are adequately fed, resulting in weight loss. Therefore, the allegation is deemed Unsubstantiated at this time.

Allegation #5: Staff does not communicate with the resident's responsible party.

It was alleged that the C1 family was not aware C1 finger nail injury. LPA interviewed four (04) staff members from 1:30 PM to 3:30 PM and requested additional documents. A review of the incident report states that facility notified them of the incident and status of the resident immediately. During interviews with staff, all staff stated they did inform family, and family called the police on them. LPA received two (2) Incident on 3.4.2025 dated 2.28.2025 and 3.3.2025

Based on interviews and records review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety issues noted at the time of this visit. An exit interview was conducted, and a copy of the report was issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC9099 (FAS) - (06/04)

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