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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609605
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:37:03 PM


Document Has Been Signed on 02/14/2024 03:37 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 CAREFACILITY NUMBER:
197609605
ADMINISTRATOR:PEREZ, ALDRINFACILITY TYPE:
740
ADDRESS:421 CORONA COURTTELEPHONE:
(213) 235-6009
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:6CENSUS: 5DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Aldrin PereTIME COMPLETED:
03:51 PM
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Licensing Program Analyst (LPA) Lorena Casillas met with administrator Aldrin Perez for an unannounced one (1) year Required visit for this facility.

LPA arrived at 12:10 pm and was greeted by a caregiver. Caregiver called Administrator and LPA informed the Administrator of the purpose of the visit. Administrator arrived at 1:10 pm.

At 12:35 p.m. LPA began a physical plant tour of the facility, and the following was observed:

There are five (5) residents in the facility. Three (3) residents are bedridden, one (1) of which is in hospice care. Two (2) residents are non-ambulatory. LPA observed all residents to be in their rooms watching TV.

Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. Knives are kept locked in a kitchen cabinet inaccessible to residents. LPA observed smoke alarms throughout the facility that are interconnected. At 1:55 p.m. all smoke alarms were tested and functioned properly. LPA observed one carbon monoxide detector and it appeared to be functioning. There is a fire extinguisher located in the kitchen last purchased on 05/24/2023.

Dining / Living Area: The dining and living area were well lit, clean, and clear of clutter. Furniture appeared clean and in good repair. A fireplace located in the living area is not in use and is blocked off making it inaccessible to residents. LPA observed the thermostat at a comfortable temperature of 76°F. There was a fire extinguisher observed by the entrance and was last purchased on 5/24/2023.

Bedrooms: There are five (5) bedrooms designated for resident use. One (1) out of the five (5) rooms is shared. All resident rooms are furnished with required lighting, dresser, chair, bed, and linens.
Continued on 809-C...
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMAZING GRACE HOME CARE
FACILITY NUMBER: 197609605
VISIT DATE: 02/14/2024
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Bathrooms: There are two (2) bathrooms designated for resident use. One (1) bathroom is located in the shared bedroom and the other main bathroom is accessible to all the residents. Both bathrooms were well lit and clean, had grab bars, had hand washing signs, nonskid mats, and trash bins with lids. LPA observed a sufficient supply of hand soap and paper towels. Water temperature in the main bathroom was measured at 115.5 degrees Fahrenheit.

Laundry Room: LPA observed the laundry room to be locked and inaccessible to residents.

Garage: LPA observed garage to be used for extra storage. There is a freezer stocked with appropriately labeled food. There is an additional supply of canned goods.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. Side gates on either side of the house were closed but unlocked. There is a covered patio to provide shade and appropriate outdoor seating for residents. LPA observed two sheds in the backyard, one (1) for storage and another one being used as an office.

Administrative: Annual fee is current. LIC 500, Liability Insurance and Client roster were collected.

Staff Files: LPA conducted a file review of staff records at 2:15 pm.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms at 2:35 pm.



Medications: At 3:05 pm LPA and Administrator reviewed medication and medication records for proper documentation.

Staff Interviews: At 3:20 pm LPA interviewed staff.

Client Interviews: At 3:45 pm LPA interviewed residents.

Exit interview conducted and a copy of this report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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