<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609605
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:56:03 PM

Document Has Been Signed on 11/29/2022 02:56 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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: 5DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Aldrin PerezTIME COMPLETED:
03:10 PM
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
On 11/29/2022 at 1:30 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual/Infection Control inspection. LPA was greeted by Staff #1 (S1) who was wearing a mask and granted access. LPA asked S1 to call administrator Aldrin Perez. Aldrin met us shortly after. LPA explained the reason for the visit. LPA reviewed the Mitigation Plan approved 09/20/2021 and an Infection Control plan submitted 06/16/2022. The inspection tool was used to complete the visit.

At 1:34 a.m. LPA began a physical plant tour of the facility and the following was observed:

Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. Cleaning solutions are locked under the sink. Knives are kept locked in a kitchen cabinet inaccessible to residents.

Dining / Living Area: The dining and living area were well lit, clean and clear of clutter. Furniture appeared clean and in good repair. A fireplace located in the living area is not in use. LPA observed proper Covid-19 signs posted through out the facility. LPA observed the thermostat at a comfortable temperature of 76°F.
The fire extinguisher was observed by the entrance and was last serviced on 12/15/2022.

Bedrooms: There are five (5) bedrooms designated for resident use. One (1) out of the five (5) rooms is shared. All resident rooms are furnished with required lighting, dresser, chair, bed, and linens.

Bathrooms: There are two (2) bathrooms designated for resident use. One (1) bathroom is located in the shared bedroom and the other main bathroom is accessible to all the residents. Both bathrooms were well lit, clean, had grab bars, had hand washing signs, nonskid mats and trash bins with lids. LPA observed a sufficient supply of hand soup and paper towels. At approximately 2 p.m. water temperature in the main bathroom was measured at 116.3 degrees Fahrenheit.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMAZING GRACE HOME CARE
FACILITY NUMBER: 197609605
VISIT DATE: 11/29/2022
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
Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. Side gates on either side of the house were closed but unlocked. There is a covered patio to provide shade and appropriate outdoor seating for residents. LPA observed two sheds in the backyard one (1) for storage and another one being used as an office.

Medications/ Resident file: LPA observed, resident medications and resident files locked in a kitchen cabinet inaccessible to residents.

LPA observed smoked alarms through out the facility that are interconnected. At 1:55 p.m. all smoke alarms were tested and functioned properly. LPA observed one carbon monoxide detector and it appeared to be functioning. Administrator states the facility has enough PPE for 30 days.



No deficiencies were observed during todays visit and the facility is currently following their infection control plan.

Exit interview conducted and a copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2