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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004696
Report Date: 11/20/2023
Date Signed: 11/20/2023 02:22:21 PM

Document Has Been Signed on 11/20/2023 02:22 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 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:
11/20/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Irish Tacsuan - House ManagerTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced inspection for the purpose of conducting a Plan of Corrections visit. LPA was greeted and granted entry by House Manager Irish Tacsuan.

LPA observed residents to be relaxing in the living room/their bedrooms. One resident was on a tablet. Hot water in the large bathroom in the main hallway measured at 118.9 degrees Fahrenheit. Hot water in the smaller bathroom in the main hallway measured at 116.6 degrees Fahrenheit. Hot water in the bathroom in one of the resident rooms measured at 117.9 degrees Fahrenheit.

Based on hot water measurements, it is determined that the facility completed their plan of corrections by the assigned due date. An exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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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