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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604814
Report Date: 08/29/2022
Date Signed: 08/29/2022 10:39:45 AM

Document Has Been Signed on 08/29/2022 10:39 AM - 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AMAZING GRACE HOME CENTERFACILITY NUMBER:
197604814
ADMINISTRATOR:GRACE O. BAJOMOFACILITY TYPE:
735
ADDRESS:8732 DEBRA AVENUETELEPHONE:
(818) 895-6332
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Grace BajomoTIME COMPLETED:
10:45 AM
NARRATIVE
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On 08/29/22 at 9:30 a.m Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with staff and then met with Administrator Grace Bajomo. The purpose of the visit was explained. Entrance interview conducted.

A physical plant tour was conducted at 9:35 a.m and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Staff took LPA’s temperature upon arrival. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medications are centrally stored in a locked cabinet in the kitchen area. Laundry area is located in the kitchen closet area. Smoke detectors/carbon monoxide are located throughout the facility. Smoke detectors and carbon monoxide detectors were tested at approximately 9:56 a.m. and appear to be functional. Fire extinguisher was observed to be in service. Common Areas: All common areas were observed to be clean and properly furnished. Clients Rooms: Facility has four (4) bedrooms which of three (3) are designated for client’s use. Facility has one live in staff. All four (4) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMAZING GRACE HOME CENTER
FACILITY NUMBER: 197604814
VISIT DATE: 08/29/2022
NARRATIVE
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Bathrooms: There are two (2) bathrooms in the facility. LPA observed all bathrooms to be cleaned. The hot water was tested and measured 133.7 F. Staff lowered the water temperature at the time of the inspection. All trash cans located in the bathrooms had tight fitting lids. Garage: The facility has an attached garage that is attached from staff’s room. The garage is used for additional storage and kept locked and inaccessible to clients Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for clients. There is a drained pool located in the backyard that is kept locked and inaccessible to clients.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency were cited (refer to LIC 809-D):

Exit interview conducted. Report signed and delivered. Appeal rights delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/29/2022 10:39 AM - It Cannot Be Edited


Created By: Joscelyn Martinez On 08/29/2022 at 10:17 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMAZING GRACE HOME CENTER
FACILITY NUMBER: 197604814

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2022
Section Cited

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80088(e)(1) Furniture, Fixtures, Equipment, and Supplies
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 and not more than 120 degrees F.
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This requirement is not met as evidenced by:
Based on observation the water measured at 133.7 during the time of the inspection.
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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022


LIC809 (FAS) - (06/04)
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