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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004696
Report Date: 10/31/2023
Date Signed: 10/31/2023 11:05:34 AM

Document Has Been Signed on 10/31/2023 11:05 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
ORANGE COUNTY ASC, 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: 6DATE:
10/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Irish Tacsuan - House ManagerTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by Caregiver Alfredo Salvador. House Manager Irish Tacsuan joined the inspection at approximately 9:15am.

The facility is a one-story home with six client bedrooms, three and a half bathrooms, kitchen, dining room, living room, two staff rooms, pantry, laundry room, backyard, attached one car garage and attached two car garage. Facility appears clean and sanitary. All resident rooms had required elements, including bed, chair, closet space and ample lighting. The restrooms are stocked with paper towels, soap and hand washing posters. Hot water in the large bathroom on the northeastern side of the facility measured at 107.9 degrees Fahrenheit. Hot water in the smaller bathroom on the northeastern side of the facility measured at 101.9 degrees Fahrenheit. Hot water in the bathroom across from large bathroom measured at 102.9 degrees Fahrenheit. Hot water in the bathroom accessible through the shared client room measured at 105 degrees Fahrenheit. LPA asked staff to adjust hot water heater, however, after giving the water time to adjust, Hot water temperatures still measured below 105 degrees Fahrenheit. A deficiency is being issued on this day. LPA observed facility has emergency food and water. Facility has a shaded seating area in the backyard and several plants. Some residents participate in gardening and taking care of the plants. LPA observed some unused wooden items/furniture in the backyard. Facility has already requested pickup for these items. The exit gates are unlocked and self-latching. Medication for each resident is kept in locked cabinets in the kitchen. LPA reviewed three of six resident files. LPA reviewed two clients’ medication. LPA reviewed four staff files. LPA observed four of the six clients in the facility were away at day program. The two clients present were not responsive to interview questions.

Based on today’s inspection, one deficiency is being issued. An exit interview was conducted and a copy of this report was provided to the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023
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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Document Has Been Signed on 10/31/2023 11:05 AM - It Cannot Be Edited


Created By: Dwayne L Mason On 10/31/2023 at 10:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMAZING GRACE GUEST HOME

FACILITY NUMBER: 306004696

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on hot water measurements, the licensee did not comply with the section cited above in two out of four hot water measurements in bathrooms that residents use. This poses a potential safety risk to persons in care.
POC Due Date: 11/14/2023
Plan of Correction
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House Manager stated that they will contact the Licensee to get someone to service the hot water heater. House Manager stated they will contact LPA by the POC due date to notify LPA of corrected hot water temperatures. LPA stated that, after the facility notifies LPA of corrected temperatures, LPA will conduct a follow up visit to verify the correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023


LIC809 (FAS) - (06/04)
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