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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609605
Report Date: 11/17/2025
Date Signed: 11/17/2025 03:02:04 PM

Document Has Been Signed on 11/17/2025 03:02 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AMAZING GRACE HOME CAREFACILITY NUMBER:
197609605
ADMINISTRATOR/
DIRECTOR:		PEREZ, ALDRINFACILITY TYPE:
740
ADDRESS:421 CORONA COURTTELEPHONE:
(213) 235-6009
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 5DATE:
11/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Aldrin PerezTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 11/17/2025 at 09:45 am Licensing Program Analyst (LPA) Lorena Casillas met with administrator Aldrin Perez for an unannounced one (1) year Required visit for this facility. LPA was greeted and granted access by Administrator. LPA explained the reason for the visit and an entrance interview was conducted.

At 10:00 am LPA conducted a facility tour with the Administrator, and the following was observed. There are five (5) residents in the facility. Four (4) residents are non-ambulatory, none of which are in hospice care and one (1) resident is ambulatory. LPA observed all residents to be in their rooms watching TV or sleeping. Facility is cleared for six (6) non ambulatory residents of which three (3) can be bedridden and an approved hospice waiver for two (2) residents.

Infection control: The facility has an Infection Control Plan approved on 03/30/2021. Proper signage was observed inside along the hallway and in the restrooms.

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 the garage and inaccessible to residents. LPA observed smoke alarms throughout the facility that are interconnected. At 10:20 a.m. all smoke alarms were tested and functioned properly. LPA observed one carbon monoxide detector, and it was tested and proved to be functioning.

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.

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMAZING GRACE HOME CARE
FACILITY NUMBER: 197609605
VISIT DATE: 11/17/2025
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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 covered and not in use. LPA observed the thermostat at a comfortable temperature of 72°F. There is a fire extinguisher located near the main entrance, and it was last purchased on 11/25/2024.

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 and clean, had grab bars, hand washing signs, nonskid mats, and trash bins with lids. LPA observed a sufficient supply of hand soap and paper towels. Water temperature in the bathrooms was measured at 110.7˚ Fahrenheit.

Laundry Room: LPA observed the laundry room to be locked and inaccessible to residents.

Garage: LPA observed garage to be used for extra storage. There is a freezer stocked with appropriately labeled food. There is an additional supply of canned goods.

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 (1) being used as an office.

Administrative: Annual fee does not reflect current, however Administrator provided proof that payment was mailed on 11/06/25. LIC 500, Liability Insurance and Resident roster were collected.

Staff Files: LPA conducted a file review of staff records at 11:30 am.

Resident Files: LPA conducted a file review of resident records at 12:00 pm.



Medications: At 2:00 pm LPA and Administrator reviewed medication and medication records for proper documentation.

Staff/Resident Interviews: At 2:25 pm LPA interviewed staff and residents.

No citations issued. Exit interview conducted and a copy of this report given to Administrator.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC809 (FAS) - (06/04)
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