331800107-9-25-2024-56-AS-KCLS-DADVRY-20241025164042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800107
Report Date: 09/25/2024
Date Signed: 09/25/2024 10:43:28 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/17/2024 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 56-AS-20240917110657

FACILITY NAME:	AMAZING GRACE CARE SERVICES LLC		FACILITY NUMBER:	331800107
ADMINISTRATOR:	MOJICA, FLORENCE A		FACILITY TYPE:	740
ADDRESS:	43 SITARA STREET		TELEPHONE:	(310) 592-5338
CITY:	BEAUMONT	STATE: CA	ZIP CODE:	92223
CAPACITY:	6	CENSUS:	DATE:	09/25/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Pauline Beltran-Support Staff		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

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Staff do not store medications so they are inaccesible to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegation. LPA met Pauline Beltran-Support Staff who was informed of the purpose of the visit and allegation.

The investigation consisted of observations,record review and interviews with support staff who stated on 9/11/2024 some medications for the residents were placed in a drawer in the refrigerator unlocked accessible to the residents, but as of 9/12/2024 the licensee has taken measures to ensure medications are locked. During the visit LPA observed in the refrigerator medications stored in a clear box with a combination lock.

Based on the information obtained during the investigation a citation was issued for not ensuring medications were inaccessible to residents in care.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 56-AS-20240917110657

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: AMAZING GRACE CARE SERVICES LLC	FACILITY NUMBER: 331800107
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/02/2024 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465- Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons....	1 2 3 4 5 6 7	The licensee has purchased a lockbox for medications to be stored in the refrigerator. The licensee has also agreed to provide training on the cited regulation & provide a signed statement of understanding by all staff members and provide proof of training by the POC date of 10/2/2024.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: based on interviews and record review the licensee didn't ensure medications were inaccessible to residents in care which pose potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20240917110657

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: AMAZING GRACE CARE SERVICES LLC	FACILITY NUMBER: 331800107
	VISIT DATE: 09/25/2024

NARRATIVE

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Based on the evidence gathered during the investigation, the above allegation is found to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where this report LIC9099, LIC9099-C and LIC9099-D was discussed and provided to Pauline Belran at the conclusion of the visit with appeal rights.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

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