197606745-9-16-2022-31-AS-ERIS-CJBPEX-20220916111552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606745
Report Date: 09/16/2022
Date Signed: 09/16/2022 11:16:13 AM

Document Has Been Signed on 09/16/2022 11:16 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AMAZING GRACE HOME CENTER II		FACILITY NUMBER:	197606745
ADMINISTRATOR:	GRACE O. OYEBOBOLA		FACILITY TYPE:	735
ADDRESS:	8539 GOTHIC AVENUE		TELEPHONE:	(818) 974-9187
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS:	DATE:	09/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Grace Oyebobola		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 9:30am Licensing Program Analysts (LPAs), Evelin Rios and Michael Cava, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff, Ajibola Akintunde, who granted access to the facility. Shortly after met with Grace Oyebobola and explained the reason for the visit. At approximately, 9:35am physical tour was conducted with the staff and LPA observed the following: Required postings were observed in the entry area. The alarms are dual smoke and carbon monoxide detectors hardwired and interconnected functions properly. The fire extinguisher is in the kitchen. The fire extinguisher was purchased 04/04/2022. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet in the kitchen. Properly labeled medications were locked in a cabinet in the kitchen. Bedrooms: There are three (3) total bedrooms. Three (3) of the bedrooms, in use by clients were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for clients' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at one out of two bathroom at 123 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were properly furnished.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMAZING GRACE HOME CENTER II	FACILITY NUMBER: 197606745
	VISIT DATE: 09/16/2022

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards. The laundry area and detergents are located by the garage. Cleaning supplies are kept in a locked cabinet in the hallway closet. It was observed locked. There is a hot tub with a cover in the backyard with no water inside.

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

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

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / A Copy of the Report Issued.

Diabetes, Mixed Developmental Disorder, cirrohsis

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/16/2022 11:16 AM - It Cannot Be Edited

Created By: Evelin Rios On 09/16/2022 at 10:42 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 II	FACILITY NUMBER: 197606745
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

This requirement is not met as evidenced by: (e)Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) 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 (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of one bathroom faucet measured at 123 degress Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2022
	Plan of Correction
1 2 3 4	Licensee adjusted the hot water heater to ensure the water temperature is measured between 105 and 120 degrees Fahrenheit. No further corrections needed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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:

Eva Miller

LICENSING EVALUATOR NAME:

Evelin Rios

LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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