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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609605
Report Date: 07/12/2022
Date Signed: 07/12/2022 02:01:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2022 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20220505141450
FACILITY NAME:AMAZING GRACE HOME CAREFACILITY NUMBER:
197609605
ADMINISTRATOR:PEREZ, ALDRINFACILITY TYPE:
740
ADDRESS:421 CORONA COURTTELEPHONE:
(213) 235-6009
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:6CENSUS: 4DATE:
07/12/2022
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Aldrin Perez, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Licensee did not clean room of a black substance on wall.

Facility does not provide food to meet the nutritious needs of the resident in care

Resident's insulin is not being administered by a nurse as perscribed by the doctor.
INVESTIGATION FINDINGS:
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At 11:05am, Licensing Program Analyst (LPA) Shira Stamps conducted a subsequent complaint visit to deliver the findings of the above allegations. Entrance interview conducted with the Administrator.

On 05-12-2022 LPA initiated the complaint investigation. LPA conducted a physical plant tour and requested and reviewed documents from 1:07pm-1:25pm. From 1:26pm-3:55pm LPA interviewed staff and residents. It is alleged that black mold or black dirt is on the wall behind the door of the resident #1(R1) bedroom. LPA observed a black substance behind the door of R1’s bedroom. LPA can’t determine if the substance is mold, but the substance should be cleaned. Therefore, based on observations the allegation, “Licensee did not clean room of black substance on wall,” is deemed substantiated.

CONTINUED...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2022 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20220505141450

FACILITY NAME:AMAZING GRACE HOME CAREFACILITY NUMBER:
197609605
ADMINISTRATOR:PEREZ, ALDRINFACILITY TYPE:
740
ADDRESS:421 CORONA COURTTELEPHONE:
(213) 235-6009
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:6CENSUS: 4DATE:
07/12/2022
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Aldrin Perez, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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2
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5
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7
8
9
Staff spoke inappropriately to a resident in care
INVESTIGATION FINDINGS:
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At 11:05am, Licensing Program Analyst (LPA) Shira Stamps conducted a subsequent complaint visit to deliver the findings of the above allegations. Entrance interview conducted with the Administrator.

It is alleged that a male staff member inappropriately spoke to a resident saying that the resident should clean their private areas with their fingers and did not provide a washcloth. LPA interviewed three (3) out of three (3) staff members, who indicated the male staff assist all residents with showering. Interviews with staff who shower the residents indicated they would instruct a female resident to clean their private areas with a washcloth and soap. Therefore, due to lack of evidence the allegation, “Staff spoke inappropriately to a resident in care,” is deemed unsubstantiated.

Exit interview conducted. Appeal rights and copy of repot delivered to Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20220505141450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMAZING GRACE HOME CARE
FACILITY NUMBER: 197609605
VISIT DATE: 07/12/2022
NARRATIVE
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It is also alleged that staff are not following the resident’s dietary needs. Interviews with residents and document review of resident files indicated that staff are providing meals that do not follow their dietary needs. Resident interviews indicated diabetic residents are receiving meals that do not follow the diabetic meal plan. Staff interviews indicated that a diabetic diet consist of no sugary foods or drinks only. Document review indicated diabetic diets should not include sugary foods or drinks, processed meals, white carbohydrates (white bread, rice, and pasta), and higher-fat cuts of meat. It was found that staff do not have full knowledge of what a diabetic diet consist of, therefore based on interview and record review the allegation, Facility does not provide food to meet the nutritious needs of the resident in care,” is deemed substantiated.

It is alleged that insulin is being administered by staff who are not a skilled professional. Interviews with residents indicated R1 is not able to administer their own insulin and staff #1 (S1) administers the insulin. Interviews with the Administrator indicated S1 worked in a skilled nursing facility and was trained on insulin administration but does not have the proper certifications. LPA reviewed the staff files and did not find a evidence that S1 is a skilled professional, but LPA did find staff received training 1/31/22 from a registered nurse on how to administer insulin injections. It was found that the facility is not following Title 22 regulation and insulin is being administered to residents by staff who are not a skilled professional, such as a certified nurse. Therefore, based on interviews and file review the allegation, “Resident’s insulin is not being administered by a nurse as prescribed by the doctor,” is deemed substantiated.

Exit interview conducted. Citations issued, appeal rights and copy of report delivered to Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20220505141450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMAZING GRACE HOME CARE
FACILITY NUMBER: 197609605
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2022
Section Cited
ILS
87303(a)
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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met as evidence by:
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During LPA observed the black substance has been cleaned. POC has been cleared during the visit.
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Based on observation, the Licensee failed to properly clean, and there is a black substance on the wall causing a potential health and safety risk to residents in care.
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Type B
07/19/2022
Section Cited
CCR
87628(b)(4)
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87628(b)(4) Diabetes. Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7).

This requirement was not met as evidence by:
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The Licensee shall submit a plan of operation on diabetic care to indicate how the facility will assists residents with diabetes. The plan will be submitted to the LPA by the POC date.
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Based on interviews and record review the Licensee failed to provide modified diets to diabetic residents in care which poses a potential health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20220505141450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMAZING GRACE HOME CARE
FACILITY NUMBER: 197609605
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2022
Section Cited
CCR
87628(a)
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87628(a) Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own… through injection, or has it administered by an appropriately skilled professional
This requirement was not met as evidence by:
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The Licensee shall ensure a skilled professional, such as a nurse, will administer insulin injections, and shall submit a plan of operation on diabetic care to indicate how the facility will have skilled professionals administer insulin. The plan will be submitted to the LPA by the POC date.
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Based on interviews the licensee failed to have a skilled professional administer insulin injections to residents in care which poses a potential health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5