331800107-5-19-2021-18-AS-CCON-C3628Y-20210518171106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800107
Report Date: 05/18/2021
Date Signed: 05/19/2021 08:14:17 AM

Document Has Been Signed on 05/19/2021 08:14 AM - 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
RIVERSIDE, CA 92507

FACILITY NAME:	AMAZING GRACE CARE SERVICES LLC		FACILITY NUMBER:	331800107
ADMINISTRATOR:	MOJICA, FLORENCE A		FACILITY TYPE:	740
ADDRESS:	43 SITARA STREET		TELEPHONE:	(310) 592-5338
CITY:	BEAUMONT	STATE: CA	ZIP CODE:	92223
CAPACITY: 6		CENSUS: 5	DATE:	05/18/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Florence Mojica - Administrator		TIME COMPLETED:	05:15 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	Licensing Program Analysts (LPAs) Crystal Colvin and Yolanda Delgado arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility via phone call. LPAs met with Administrator Florence Mojica and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control. Below is a summary of what was observed: Infection Control: LPAs Colvin and Delgado went over COVID-19 best practices for infection control and prevention with Administrator Florence Mojica, who has not yet submitted a COVID-19 Mitigation Plan for the facility to Community Care Licensing (CCL). Mitigation Plans were to be submitted to CCL for all facilities back in January 2021. LPA Colvin and Delgado will be issuing a Technical Assistance (TA) Advisory Note, as the Administrator is actively working on the Mitigation Plan. LPAs toured the facility and observed multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for local fire department and resident's physician's. LPA Colvin and Delgado checked the hand-washing stations (bathrooms) in the facility and observed there to be plenty of soap and hand sanitizer, but no paper towels for residents to use to dry their hands. LPAs Colvin and Delgado are issuing a Technical Violation (TV) for the facility not meeting this area of infection control, due to CCL focusing on providing support to facilities during the COVID-19 pandemic. LPA Colvin and LPA Delgado requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was conveniently located in the entryway of the facility. LPAs observed the facility to have all PPE supplies except for N95 masks, which are required if the facility were to have a COVID-19 positive resident in the facility. It is best practices to have all PPE items on hand, so that the facility staff can immediately have access to all needed items, should a resident test positive. LPA Colvin and LPA Delgado are issuing a TA Advisory Note, due to the facility not currently having a positive COVID-19 case at the facility, and residents and staff already being vaccinated. LPAs confirmed with Administrator Florence Mojica that the facility has a plan for isolating resident(s) should they test positive for COVID-19.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

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 12

Document Has Been Signed on 05/19/2021 08:14 AM - It Cannot Be Edited

Created By: Crystal Colvin On 05/18/2021 at 03:24 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AMAZING GRACE CARE SERVICES LLC	FACILITY NUMBER: 331800107
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in numerous items around the backyard and side yard(s) of the facility, wherein debris and discarded items were left laying around. One such item included a board of wood with three screws sticking out. This poses a potential safety and personal rights risk to persons in care.
	POC Due Date: 05/21/2021
	Plan of Correction
1 2 3 4	Licensee agrees to remove discarded items which are not in use by the facility by the Plan of Correction date of 5/21/21. Licensee to submit photographic proof to LPA Colvin by POC date.

Type B

Section Cited

CCR

87307(d)(2)

Personal Accommodations and Services

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based onobservation, the Licensee did not comply with the selection cited above in at least four entrances/exits to the facility, as LPAs observed metal ramps to be loose and not connected to the ground or building. LPAs observed several of the ramps to be over two inches away from the entryway of the doors. This poses a potential safety risk to persons in care.
	POC Due Date: 05/21/2021
	Plan of Correction
1 2 3 4	Licensee agrees to have the metal ramps modified so that they do not move and are sturdy for resident use. Licensee may self-certify to LPA Colvin what was done to complete this task by the Plan of Correction date of 5/21/21.

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

SUPERVISOR'S NAME:

Joel Esquivel

LICENSING EVALUATOR NAME:

Crystal Colvin

LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

Page: 2 of 12

Document Has Been Signed on 05/19/2021 08:14 AM - It Cannot Be Edited

Created By: Crystal Colvin On 05/18/2021 at 03:24 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AMAZING GRACE CARE SERVICES LLC	FACILITY NUMBER: 331800107
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in at least one room of the facility (garage) where LPAs Colvin and Delgado were able to access bleach without isssue. This poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/19/2021
	Plan of Correction
1 2 3 4	Licensee agrees to immediately lock up all chemicals so that residents do not have access to harmful prodcuts. Licensee additionally agrees to complete a search of the facility for additional accessible chemicals to ensure that there are no other hazards present. Licensee may self-certify to LPA Colvin once this task is complete. Plan of correction date of 5/19/21.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based onobservation, the licensee did not comply with the section cited above in four areas of the facility (cabinet in kitchen, drawer in kitchen, top of medicine cabinet, unlocked medicine cabinet) which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/19/2021
	Plan of Correction
1 2 3 4	Licensee agrees to immediately lock up all prescription and non-prescription medications so that residents do not have access to potentially harmful prodcuts. Licensee additionally agrees to complete a search of the facility for additional accessible medications to ensure that there are no other hazards present. Licensee may self-certify to LPA Colvin once this task is complete. Plan of correction date of 5/19/21.

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

SUPERVISOR'S NAME:

Joel Esquivel

LICENSING EVALUATOR NAME:

Crystal Colvin

LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

Page: 4 of 12

Document Has Been Signed on 05/19/2021 08:14 AM - It Cannot Be Edited

Created By: Crystal Colvin On 05/18/2021 at 03:24 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AMAZING GRACE CARE SERVICES LLC	FACILITY NUMBER: 331800107
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 5 staff members (S1) which poses an immediate safety risk to persons in care.
	POC Due Date: 05/19/2021
	Plan of Correction
1 2 3 4	Licensee agrees to remove S1 from the facility immediately and update the staff schedule until S1 obtains a criminal record clearance. Licensee to submit updated staff schedule to LPA Colvin by 5/19/21.

Type A

Section Cited

CCR

87355(e)(1)

Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 5 staff members (S2) which poses an immediate safety risk to persons in care..
	POC Due Date: 05/19/2021
	Plan of Correction
1 2 3 4	Licensee agrees to remove S2 from the facility immediately and update the staff schedule until S2 obtains a criminal record clearance. Licensee to submit updated staff schedule to LPA Colvin by 5/19/21.

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

SUPERVISOR'S NAME:

Joel Esquivel

LICENSING EVALUATOR NAME:

Crystal Colvin

LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

Page: 6 of 12

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
RIVERSIDE, CA 92507

FACILITY NAME: AMAZING GRACE CARE SERVICES LLC	FACILITY NUMBER: 331800107
	VISIT DATE: 05/18/2021

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

LPA Colvin and LPA Delgado went over the various recommended training for facility staff with Administrator Florence Mojica in relation to COVID-19, and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

LPA Colvin and Delgado inquired as to if staff have been fit tested for N95 masks, and Administrator Florence Mojica informed LPAs that some staff have been fit tested, but that newly hired staff have not. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, residents have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Colvin informed Administrator Florence Mojica of Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

Additional Observations: During today's inspection, additional items were observed to be out of compliance with Title 22 Regulations and were addressed by LPAs Colvin and Delgado. Upon arrival to the facility, LPAs learned from staff that there was no Administrator, facility manager, or other individual in charge on site. Title 22 states that there must be someone on site at all times which acts as a representative for the facility in the absence of the Administrator. LPA Colvin and LPA Delgado will be issuing a TV Advisory Note today instead of a deficiency, as the Administrator was able to arrive to the facility during today's inspection and assist LPAs with completing the Annual Inspection. Additionally, LPA Colvin and Delgado observed the facility to not have a clothing dryer on the premises due the facility's clothing dryer breaking the previous day (according to staff). LPAs will be issuing a TV Advisory Note today instead of a deficiency as the Administrator is actively working on getting the dryer repaired or replaced.

While touring the facility, LPA Colvin and Delgado observed chemicals (bleach) located in the unlocked garage, which were readily accessible without staff assistance. This is an immediate health and safety risk to residents in care, and therefore a deficiency is being issued. LPA Colvin and Delgado additionally observed numerous areas throughout the facility where medication (both prescribed and over-the-counter) were unlocked and readily accessible. This is an immediate health and safety risk and a deficiency was cited by LPAs during today's inspection.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

Page: 8 of 12

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
RIVERSIDE, CA 92507

FACILITY NAME: AMAZING GRACE CARE SERVICES LLC	FACILITY NUMBER: 331800107
	VISIT DATE: 05/18/2021

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

While touring the perimeter of the facility, LPAs Colvin and Delgado observed numerous debris (such as torn trampoline, planks of wood with screws, and discarded blinds) strewn about the yard. This poses a potential safety risk and personal rights violation to residents, as the facility is to be kept in good repair at all times. Deficiency cited. Additionally, LPAs observed metal ramps near the entrances/exits of the facility which were not secured to either the ground or the door, which poses a potential fall risk to residents. LPAs observed some of the ramps to have a large gap between the building and the ramp, where a resident could fall by missing the ramp when stepping out of the door. Deficiency cited.

Lastly, LPAs Colvin and Delgado reviewed the current staff roster and observed that two staff members (S1 & S2) were not on the facility's roster. LPA Delgado contacted CCL Riverside Office to inquire as to the clearance status of S1 & S2 and further learned that neither staff member had an active criminal background clearance. LPA Colvin additionally accessed the Licensing system remotely to confirm this. Administrator provided LPAs with one of the staff member's receipt for Livescan, which LPA Colvin reviewed and determined had not been completed properly. LPA Colvin double checked the Licensing system which showed the staff member's information in the system, but additionally indicated that there were no fingerprints on file, so the clearance check through the Department of Justice had not been run. Staff are not permitted to work in CCL facilities until a criminal background clearance has been run through the Department of Justice and there is confirmation of no criminal history which would prevent the staff member from working at the facility. A deficiency is being cited for each staff member and civil penalties are being assessed for $300 for S1 (due to S1 only having work 3 days according to the Administrator) and $500 for S2 (as S2 has been working since April 2021). Formula for civil penalties is $100 per day for a maximum of 5 days ($100 x 3 = $300 & $100 x 5 = $500). Total amount of civil penalties assessed is $800. Additionally, S1 and S2 must vacate the facility immediately and may not return until they have confirmed criminal record clearance from the Department of Justice. The Administrator agrees to ensure adequate staff coverage at the facility until S1 and S2 can return.

An exit interview was conducted with Administrator Florence Mojica and a copy of this report, LIC9102 TA Advisory Note, LIC9102 TV Advisory Note, LIC809D, and copy of appeal rights were provided.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

Page: 9 of 12