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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800107
Report Date: 04/23/2024
Date Signed: 04/23/2024 02:23:10 PM

Document Has Been Signed on 04/23/2024 02:23 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AMAZING GRACE CARE SERVICES LLCFACILITY NUMBER:
331800107
ADMINISTRATOR/
DIRECTOR:		MOJICA, FLORENCE AFACILITY TYPE:
740
ADDRESS:43 SITARA STREETTELEPHONE:
(310) 592-5338
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 6CENSUS: 5DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Teresa EspinozaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Teresa Espinoza, Supervisor, and discussed the purpose of the visit.

The facility is a single story, (5) bedroom, (3) bathroom, Residential Care Facility for the Elderly (RCFE) with a license capacity of (6) and a current census of (5) residents in care. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:
Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor shaded area is sufficient for resident activities and is enclosed with a self-latching gate. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s showers, toilets, and hand washing areas were in operating condition and equipped with grab rails and non-slip mats. The hot water temperature in residents' bathrooms measured 108 and 117 degrees F. Resident’s bedrooms had beds, bed linen, dressers and sufficient lighting. The facility has operating carbon monoxide alarms and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, Community Care Licensing complaint poster, Ombudsman poster, Resident's Personal Rights, evacuation exit plan and emergency telephone numbers. Sharps, disinfectants, and cleaning solutions are kept in a locked cabinet inaccessible to residents in care.
Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. The facility's refrigerator and freezer were operating in a healthful manner.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AMAZING GRACE CARE SERVICES LLC
FACILITY NUMBER: 331800107
VISIT DATE: 04/23/2024
NARRATIVE
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Care & Supervision: Facility has 24-hour, 7 days a week care staff, staff present at the facility had criminal record clearances with the Department.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet.

Record Review: The facility’s Administrator’s certification and liability insurance are current. The facility’s last fire drill was conducted on 1/10/24. LPA review of staff files reveals, staff #1 (S1), staff #2 (S2), and staff #3 (S3) did not have record of tuberculosis results and did not have an employment record/application containing Employee's full name, Social Security number, date of employment, home address on file. In addition, the facility did not maintain record of S3's first aid/CPR and dementia training. LPA review of resident files reveal, resident #1 (R1), resident #2(R2), resident #3(R3), resident #4 (R4) did not record of tuberculosis results. In addition, the facility did not maintain record of a pre-admissions appraisal for R1. LPA review of facility's hospice waiver reveals the facility has an approved hospice waiver for (2) residents; however, all (5) residents are receiving hospice care.

Based on observations and record review, deficiencies are being cited per Title 22, of The California Code of Regulations and Health and Safety codes.

This report was reviewed with Supervisor Espinoza and a copy with Appeal Rights was provided to Supervisor Espinoza and the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 04/23/2024 02:23 PM - It Cannot Be Edited


Created By: Magda Malcore On 04/23/2024 at 12:04 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AMAZING GRACE CARE SERVICES LLC
FACILITY NUMBER: 331800107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Hospice Care for Terminally Ill Residents
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type A
Section Cited
CCR
87633(a)(1)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above by not having an approved hospice waiver for (5) residents; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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The Licensee/Administrator shall read regulation 87632 Hospice waiver and submit to the Licensing Agency a hospice increase waiver request by POC due date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 04/23/2024 02:23 PM - It Cannot Be Edited


Created By: Magda Malcore On 04/23/2024 at 12:04 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AMAZING GRACE CARE SERVICES LLC
FACILITY NUMBER: 331800107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by Staff #1, #2, #3 did not have record of tuberculosis results on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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The Licensee/Administrator shall submit to the Licensing agency documentation of staff's tuberculosis results by POC due date.

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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 04/23/2024 02:23 PM - It Cannot Be Edited


Created By: Magda Malcore On 04/23/2024 at 12:04 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AMAZING GRACE CARE SERVICES LLC
FACILITY NUMBER: 331800107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(1)(2)(3)(5)
Personnel Records
The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (1) Employee's full name. (2) Social Security number. (3) Date of employment..(5) Home address and telephone number...this requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited by not having record of employment record/application for staff #1, staff#2, staff#3, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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The Licensee/Administrator shall submit to the Licensing Agency documentation of employment record/application by POC due date.
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by not maintaining record of S3's first aid/CPR and dementia training; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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The Licensee/Administrator shall submit to the Licensing Agency documentation of staff training by POC due date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 04/23/2024 02:23 PM - It Cannot Be Edited


Created By: Magda Malcore On 04/23/2024 at 12:04 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AMAZING GRACE CARE SERVICES LLC
FACILITY NUMBER: 331800107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Requirements - General
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by resident #1 did not have record of a preadmission appraisal on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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4
The Licensee/Administrator shall read and submit a statement of understanding of the cited regulation and submit the statement to the Licensing Agency by POC due date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024


LIC809 (FAS) - (06/04)
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