331880659-4-1-2025-56-AS-MBRN-DFBUR9-20250401154823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880659
Report Date: 04/01/2025
Date Signed: 04/01/2025 03:48:42 PM

Document Has Been Signed on 04/01/2025 03:48 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	AMAZING GRACE HOME CARE		FACILITY NUMBER:	331880659
ADMINISTRATOR/ DIRECTOR:	TRIAS, MARY GRACE		FACILITY TYPE:	740
ADDRESS:	31485 MANDY CT		TELEPHONE:	(951) 660-8564
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	04/01/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:38 AM
MET WITH:	Licensee/Administrator Mary Grace Trias		TIME VISIT/ INSPECTION COMPLETED:	03:50 PM

NARRATIVE

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On 04/01/2025 at 11:38 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct the required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. Licensee/Administrator Mary Grace Trias was informed of the visit. LPA Brown informed Licensee/Administrator Trias of the purpose of the visit. At the time of the visit there were two (2) staff present, and three (3) residents present.

The facility is a four (4) bedroom, three (3) bathroom home with a kitchen/dining area, living room/activity room, laundry room and an attached garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents of which one (1) may be bedridden. The facility’s approved for six (6) hospice waiver. The current census is four (4) residents. LPA Brown was accompanied by Licensee/Administrator Trias to conduct a general overall inspection, which included, but was not limited to the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 70 degrees Fahrenheit (F). LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in the residents bathroom to be at 112.8 degrees F. The facility is equipped with operating combined smoke detectors and carbon monoxide alarms. Charged fire extinguisher was also observed at the facility. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster, and the disaster plan, House Ruled and Visitation Policy were posted in a common area. ***Continuation in LIC809C ***

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 04/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: AMAZING GRACE HOME CARE	FACILITY NUMBER: 331880659
	VISIT DATE: 04/01/2025

NARRATIVE

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However, LPA Brown noted that the facility did not review the Emergency Disaster Plan (LIC610D) annually and no Licensee or Administrator signature and signature date. Deficiency will be issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There's a designated storage space for resident/staff files.

There is a medicine cabinet with the resident’s medications locked. LPA Brown observed the complete first aid kit however, no first aid book observed at the facility. Deficiency will be issued. Moreover, LPA Brown noted that the facility has the required emergency supplies, emergency food and emergency water maintained.

Food Service: More than seven (7) days’ supply of non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has an Administrator present at the facility with appropriate and enough hours to appropriately manage the facility. However, LPA Brown observed that the facility does not have a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents that are reported by their physician in Physician Report (LIC602) with sun downing or wandering behavior. Deficiency will be issued.

Record Review: LPA Brown noted that the facility has an updated Infection Control Plan and updated Liability Insurance. LPA Brown reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisals, centrally stored medication list/physician orders and needs and services plans. LPA Brown observed resident files reviewed were complete. In addition, LPA Brown noted that Resident #2 (R2) half bed rail has written orders from R2's physician indicating the need for half bed rail for mobility. LPA Brown reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed that Staff #1 (S1) First Aid/CPR Certification expired on 03/2025. Deficiency will be issued. However, Licensee/Administrator Trias informed LPA Brown that no trainings were provided by the two (2) Hospice Agencies to facility staffs for implementation of the hospice care plan. Deficiency will be issued.

During medication audit, LPA Brown observed that staffs at the facility are assisting their residents with their self-administered medication per their doctor's order. No issues observed.

Based on the observations made during today’s visit, deficiencies and technical assistance were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations (CCR).

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/01/2025 03:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 HOME CARE	FACILITY NUMBER: 331880659
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #1 (S1) has an updated First Aid/CPR Certification as required which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/02/2025
	Plan of Correction
1 2 3 4	Licensee submitted proof of S1 updated First Aid/CPR Certification to LPA Brown during the visit today, 04/01/2025. Plan of Correction (POC) cleared.

Type A

Section Cited

CCR

87705(b)(2)

Care of Persons with Dementia

(b) Licensees shall be responsible for the following: (2)For facilities with fewer than 16 residents, ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal, or observation, to require awake night supervision. This requirement is in addition to requirements specified in Section 87415, Night Supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a staff scheduled to work the night shift, awake and on duty as required for facility with dementia resident that's reported by their physician with sun downing or wandering behavior which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/02/2025
	Plan of Correction
1 2 3 4	Licensee stated to submit an updated Personnel Report (LIC500) showing a staff scheduled to work the night shift, awake and on duty as required for facility with dementia resident that's reported by their physician with sun downing or wandering behavior to LPA Brown by the 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.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 04/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/01/2025 03:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 HOME CARE	FACILITY NUMBER: 331880659
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.695(d)

Other Provisions

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the Licensee or administrator review, sign and date the Emergency Disaster Plan (LIC610D) as required which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2025
	Plan of Correction
1 2 3 4	Licensee stated to review, sign and date form LIC610D and submit a copy to LPA Brown by the Plan of Correction (POC) due date.

Type B

Section Cited

CCR

87633(b)(6)

Hospice Care for Terminally Ill Residents

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the hospice agency will provide training to facility staffs relating to licensee's responsibilities for implementation of the hospice care plan which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	Licensee stated to coordinate with the residents hospive agencies to provide the required training to facility staff and submit proof of staff training to LPA Brown by the 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.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 04/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/01/2025 03:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 HOME CARE	FACILITY NUMBER: 331880659
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87465(a)(8)(A)

Incidental Medical and Dental Care Services (8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and ecord review, the licensee did not comply with the section cited above by not ensuring that a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency is maintained at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/02/2025
	Plan of Correction
1 2 3 4	Licensee stated to obtain or purchase a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency and submit proof to LPA Brown by the Plan of Correction (POC) due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 04/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: AMAZING GRACE HOME CARE	FACILITY NUMBER: 331880659
	VISIT DATE: 04/01/2025

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	An exit interview was conducted, and this report (LIC809), LIC809D, LIC9102 and Appeal Rights were discussed and provided to Licensee/Administrator Mary Grace Trias.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025

LIC809 (FAS) - (06/04)

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