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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004252
Report Date: 03/03/2022
Date Signed: 03/03/2022 10:14:59 AM


Document Has Been Signed on 03/03/2022 10:14 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:AMAZING GRACE & CAREFACILITY NUMBER:
306004252
ADMINISTRATOR:LIVIU BORFACILITY TYPE:
740
ADDRESS:900 N. CARHART AVENUETELEPHONE:
(714) 870-0309
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 5DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elena Bor, AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by Administrator. LPA met with Elena Bor, Administrator and explained the nature of the visit.

LPA Martinez began the tour of the inside and outside of the facility accompanied by Administrator. There are five residents in care and there are no active covid-19 cases in the facility. LPA observed three residents in the living room watching television and the remainder of residents in their bedrooms. All resident appeared to be clean and well taken care of. LPA observed required department posting, covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All restrooms observed to have ample supply of soap and appeared to be clean. LPA inspected residents’ bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed a check in station in the main entry of the facility. Facility is taking temperature daily and documenting the results. LPA observed the emergency disaster and evacuation plan. Facility has the back-up emergency food and water supply as well as PPE supplies in the garage. LPA toured the outside of the facility and observed a shaded seating area for resident’s enjoyment. LPA observed a gated pool area inaccessible to residents. The facility has a second floor which is occupied by Administrator and residents have no access. The facility has completed the LIC808 Mitigation Plan, LPA reviewed and approved the plan on today’s visit.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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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