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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606745
Report Date: 12/06/2023
Date Signed: 12/06/2023 03:06:31 PM

Document Has Been Signed on 12/06/2023 03:06 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AMAZING GRACE HOME CENTER IIFACILITY NUMBER:
197606745
ADMINISTRATOR:GRACE O. OYEBOBOLAFACILITY TYPE:
735
ADDRESS:8539 GOTHIC AVENUETELEPHONE:
(818) 221-3015
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Grace Oyebobola, Administrator TIME COMPLETED:
03:00 PM
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At 1:30pm Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA were greeted by the Staff #1, Josepine Osede, who granted access to the facility. LPA met with the Administrator and explained the reason for the visit. Physical tour was conducted with the Administrator and LPA observed the following:

Kitchen: At approximately, 1:35pm LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked under the kitchen sink and inaccessible to clients in care. Fire extinguisher in the kitchen, was last serviced on 05/22/2023.

Medications: At approximately, 1:40pm LPA observed medications are centrally stored and locked in the kitchen cabinet.

Bedrooms: Facility has three (3) bedrooms designated for clients use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Staff bedroom was observed to be locked and inaccessible to clients in care.

Bathrooms: LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. Hot water temperature measured at 116.2°F.


Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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 II
FACILITY NUMBER: 197606745
VISIT DATE: 12/06/2023
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Common Areas: The facility maintains a comfortable temperature at 72°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture and the fireplace is adequately screened. No obstructions and or tripping hazards throughout the facility. Laundry is located in the attached garage that can be accessed through the staff's bedroom. LPA observed all detergents locked and inaccessible to clients in care.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 1:50pm they were tested and observed to be operational. Carbon monoxide was located in a hallway and was also tested and observed to be operational.

Outside areas: At approximately, 1:55pm LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients.



Between 2:00pm to 2:30am, LPA reviewed records of four (4) clients and two (2) staff. Client and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

No deficiency cited during todays visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC809 (FAS) - (06/04)
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