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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603680
Report Date: 11/02/2023
Date Signed: 11/02/2023 11:52:47 AM

Document Has Been Signed on 11/02/2023 11:52 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AMAZING GRACE HOMES LLCFACILITY NUMBER:
198603680
ADMINISTRATOR:OYELEYE, TAIWOFACILITY TYPE:
735
ADDRESS:17639 1/2 VIRGINIA AVETELEPHONE:
(562) 841-2920
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 0DATE:
11/02/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Taiwo Oyeleye - AdministratorTIME COMPLETED:
12:07 PM
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an announced Pre-Licensing visit and met with Administrator Taiwo Oyeleye for the purpose of conducting a Pre-Licensing Inspection / Component III visit. This was the facility’s first Pre-Licensing Inspection its initial application.

The facility has an approved fire clearance to be licensed to serve four (4) ambulatory clients. The facility is a two-story home in a residential neighborhood. It contains three (3) bedrooms, three (3) restrooms, a living room, a dining room, a laundry room, a kitchen, an attached garage, and a back yard patio area located in Bellflower, California.

The physical plant was toured inside and out alongside Taiwo Oyeleye. The Pre-Licensing Inspection Tool was used.

The following was observed/inspected:

· There is a locked storage area that is centrally located for medication located in the kitchen area of the facility.

· Cleaning supplies are kept separate from food and located in a locked cabinet under the kitchen sink.

· Facility walls, ceilings, floors, window screens and areas around the facility are clean and in good repair.

· Fire extinguishers and smoke detectors operate properly.

· Doors and passageways are free of obstruction.

· There are no pools/bodies of water at the facility.

· Facility does not have firearms on premises.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AMAZING GRACE HOMES LLC
FACILITY NUMBER: 198603680
VISIT DATE: 11/02/2023
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· Facility sketch and sample menus were posted and visible within the facility.

· There is an emergency exiting plan with emergency phone numbers posted and visible within the facility.

· Facility has a current disaster and mass casualty plan maintained at the facility.

· There is a plan for employee accommodations and staffing arrangements.

· Operating telephone is on the premises and will be available to clients.

· Vehicles to transport clients are maintained and in operation condition.

· The facility does not currently have clients therefore no client records were reviewed.

· First-aid supplies are maintained and readily available.

· Refrigerator and freezer were observed and are maintained at the correct temperatures.

· Food storage and preparation are clean and appropriate for food preparation.

· Hot water temperature was tested and is within the required range of 105-120 degrees F.

Component III was completed during the visit today on 11/2/2023.

An exit interview was conducted, and a copy of this report has been furnished to Administrator Taiwo Oyeleye. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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