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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604814
Report Date: 08/05/2024
Date Signed: 08/08/2024 01:43:35 PM

Document Has Been Signed on 08/08/2024 01:43 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AMAZING GRACE HOME CENTERFACILITY NUMBER:
197604814
ADMINISTRATOR/
DIRECTOR:		GRACE O. BAJOMOFACILITY TYPE:
735
ADDRESS:8732 DEBRA AVENUETELEPHONE:
(818) 895-6332
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 3DATE:
08/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:17 AM
MET WITH:Grace Bajomo- AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff, Lionel Tiomela and explained the reason for the visit. Approximately, around 10:30 AM administrator Grace Bajomo arrived and was explained for the reason of the visit.

At 10:35 AM, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 5/10/2024. During the visit the facility is at 74 degrees Fahrenheit. The facility is fire cleared for four (04) mentally unstable individuals.

Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in the dining area drawer in the kitchen.

Bedrooms: There were four (4) bedrooms designated for residents' and staff use. Three (3) of the that are in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Room #1 and #2 are properly furnished and occupied by only one (1) resident. Room #3 is shared room. There is one (1) staff bedroom in the facility and is located beside at the end of the hallway staff bedrooms are locked with no medication in sight.

Bathrooms: There are two (2) bathrooms designated for residents' and staff use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 110.1 degrees Fahrenheit for bathroom #1 located inside bedroom #3. Bathroom #2 measured 118.8 degrees Fahrenheit located in the hallway beside staff room.
Continue to LIC 809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/05/2024
NARRATIVE
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Cleaning supplies are being stored in a locked cabinet in the hallway. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area are located by the kitchen. The facility does have a swimming pool or body of water. The garage is detached and is used for storage for incontinence for residents and staff refrigerator.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records (MMR) were review, R2 medication for Quetiapine was given at a wrong time, deficiency will be cited on LIC 809-D.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies observed during the visit will be on LIC 809-D. Exit interview conducted and a copy of the report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/08/2024 01:43 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 08/05/2024 at 01:42 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
, 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: 08/05/2024

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 record review, the licensee did not comply with the section cited above in 1 out of 3 medication on Quetiapine was given at a wrong time which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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S3 needs to be re-trained on proper medication handling. Administartor will send certication to LPA.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/08/2024 01:43 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 08/05/2024 at 01:42 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
, 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: 08/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)(4)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information: (4) The maximum number of doses allowed in each 24-hour period.

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 1 out of 3 Quetiapine was given at a wrong time which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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S3 needs to be re-trained on proper medication handling. Administartor will send certication to LPA.

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:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024


LIC809 (FAS) - (06/04)
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