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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004252
Report Date: 10/21/2025
Date Signed: 10/21/2025 03:03:29 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2022 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220512152957
FACILITY NAME:AMAZING GRACE & CAREFACILITY NUMBER:
306004252
ADMINISTRATOR:ELENA BORFACILITY TYPE:
740
ADDRESS:900 N. CARHART AVENUETELEPHONE:
(714) 870-0309
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: DATE:
10/21/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Elena BorTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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- Staff did not call 911 for residents -Staff took resident's call pendant
- Staff did not notify resident authorized - Staff is opening resident's mail
representative of incidents - Staff is being disrespectful to resident
- Staff are over dosing residents - Facility is not at a comfortable temperature for resident's
- Staff are not providing adequate food service for resident's - Staff is financially abusing resident
- Staff are not meeting resident's toileting needs
- Staff are charging resident for services not received
- Staff did not have resident's authorized represtantative sign admissions agreeemnt for change in level of care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude the investigation into the above identified complaint allegations. LPA arrived at the facility and was greeted and granted entry by care staff. LPA spoke with Elena Bor, Administrator and explained the purpose of the visit.

Findings are based upon this investigation which included tour of the facility, facility file review, resident file review, interviews conducted, and pertinent documents collected.

It is alleged staff did not call 911 for resident. Record review revealed that licensee/administrator has submitted various LIC624 unusual incident reports for the year 2022. Interview with staff stated that

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
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 4
Control Number 22-AS-20220512152957
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AMAZING GRACE & CARE
FACILITY NUMBER: 306004252
VISIT DATE: 10/21/2025
NARRATIVE
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resident (R1) didn’t have an incident that need 911 to be call or reported out to the department. Interview with R1 stated that they did not have any incidents that needed the assistance of 911. Interview with 3 of 3 residents stated that owner calls 911 when necessary and when it is needed.

It is alleged that staff did not notify residents authorized representative of incidents. Interview with witnesses stated that facility licensee calls them and keeps them informed. Review of the records revealed that reports state that responsible party and/or authorized representative were notified. Interview with Administrator stated that they kept families, representatives and/or authorized representative informed of any incidents, changes in condition or any information.

It is alleged that staff are overdosing residents, specifically with giving R1 sleeping medication. Interview with 3 of 3 residents indicated that staff give them medication and they have not had any issues with medication. Record review revealed that there is no medication on record for sleep aid for any resident. Medication list do reflect medication for agitation and anxiety but not sleeping aids. Records reflect consistency with medication list and very minor changes are reflected.

It is alleged that staff are not providing adequate food service for resident’s, specifically to licensee providing food from their own home and family meals. Interview with licensee stated that they have always lived on the second floor of the facility and they do not have another family home in where they would go to and make meals to bring back. Interview with 3 of 3 residents stated that the meals provided are good and they have no issues with the food. LPA toured the facility kitchen and observed that the meal prepared appeared of good quality and storage areas organized. LPA inspected food supply adequate amount was observed to be within regulations. The facility has a two-day supply of perishables, and seven-day supply of non-perishable food is available as required by regulations.

It is alleged that staff are not meeting resident’s (R2) toileting needs. Record review revealed that R2's fees reflect for level 2 minimal care and supervision. Residents at this level are mildly confused, need verbal

Continued on LIC9099-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20220512152957
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AMAZING GRACE & CARE
FACILITY NUMBER: 306004252
VISIT DATE: 10/21/2025
NARRATIVE
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reminders to perform hygiene functions, uses walker or wheelchair, has occasional episodes of incontinence, mild emotions or behavior issues, medically stable, special diet or weight issues. Interview with R2 stated that they get the help they need and get help when they need to go to the bathroom. Interview with 3 of 3 residents stated that they get help when they need it.

It is alleged that staff are charging resident for services not received, specifically to night supervision. Interview with licensee/administrator stated that they do the night shift, they live in the facility and provide the care at night. . Interview with Interview with 3 of 3 residents stated that they get the care they need at night and/or have seen the staff providing care at night to the residents.

It is alleged that staff did not have resident's authorized representative sign updated admissions agreement for change in level of care. Record review revealed that LPA obtained copies of resident that resided at the time of filed complaint from the facility. It was observed that only one resident reflected a changed of level of care. Records revealed that resident (R3) had a change of level in care on June 1st and paperwork was signed. R3 admissions to facility was March 2, 2022.

It is alleged that staff took resident’s call pendant, specifically to resident (R4). Interview with resident stated that they never had a call pendant. Interview with staff stated that there was residents that had a call pendant.

It is alleged that staff is opening resident’s mail, specifically to R4’s mail. Interview with resident stated that their mailing address is their home and not the facility. Their mail gets retrieved from the home and brought back to the facility with them. Interview with staff stated that residents do not get their mail sent to the facility but that they had that option to do so. However, most residents family choose not to and bring residents mail if necessary to the resident to the facility.

It is alleged that staff is being disrespectful to residents. Interview with 4 of 4 residents stated that the staff is good to them, are not rude to them at all and they treat them with respect at all times. Interview with staff stated that they do the best they can and treat all residents with respect and do the best they can to keep all residents well cared for and happy.

Continued on LIC9099-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20220512152957
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AMAZING GRACE & CARE
FACILITY NUMBER: 306004252
VISIT DATE: 10/21/2025
NARRATIVE
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It is alleged that facility is not a comfortable temperature for resident’s. Interview with staff stated that the facility has a central air system to control the entire house. Interview with 4 of 4 residents stated that the temperature is never too cold or too hot that it is fine for them. LPA toured the facility and observed the temperature outside was 66.9 Fahrenheit degrees and the temperature inside the facility measured at 73.9 Fahrenheit degrees which is within regulations.

It is alleged that staff is financially abusing resident, specifically monthly dues checks paid to the Administrator. Record review revealed that Administrator is also the licensee of the facility and therefore fees are paid to the licensee.

Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated.

An exit interview was conducted with the Administrator and a copy of this LIC9099 report was left at facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4