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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004696
Report Date: 02/28/2023
Date Signed: 02/28/2023 02:53:24 PM

Document Has Been Signed on 02/28/2023 02:53 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AMAZING GRACE GUEST HOMEFACILITY NUMBER:
306004696
ADMINISTRATOR:NORAJOY I. KINNEYFACILITY TYPE:
735
ADDRESS:12192 NUTWOOD STREETTELEPHONE:
(714) 537-7630
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 5DATE:
02/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Norajoy Kinney, AdministratorTIME COMPLETED:
03:05 PM
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On this day, Licensing Program Analyst (LPA) made an unannounced visit to the facility for the purpose of conducting a case management visit related to the allegations being investigated at God Blessing Home - 306003987.

Staff confirm that client C1 was recently relocated from the facility listed above a few weeks prior to the visit.

Client C1 is observed coming back from Day Program accompanied by his father. LPA attempted to interview C1 and conducted an interview with the client's father after he dropped his son off.

LPA conducted a brief interview with facility staff and facility administrator regarding client C1's transfer.

No deficiencies cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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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