AMAZING GRACE CARE SERVICES LLC

Official classification

Type A

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2026 Plan of Correction Licensee will have the residents obtain a TB test notify LPA when completed by POC, than send a copy of the results to LPA

Official classification

Type B

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2026 Plan of Correction Licensee will correct the water temperature and will send a copy of the new water temperature that it was adjusted to by POC due date

Official classification

Type B

Official code

87465(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by initialing medication was given to R5, when the resident was actually hospitalised which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2026 Plan of Correction Licensee to create a policy on charting errors and conduct a training with staff on charting errors.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not having completed appraisal on file for R1,R3 and R5 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2026 Plan of Correction Licensee to review all residents files and ensure all have completed appraisals. Licensee will send copy of the completed appraisals for R1,R3 and R5

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not ensuring that the residents centrally stored medication list is recorded for the month of October for all the residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/07/2025 Plan of Correction Licensee/Administrator agrees to submit a statement of understanding on the regulation cited above by plan of correction (POC) due date.

Official classification

Type A

Official code

87458(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that R3 and R4 has the physician report with tubeculosis (TB) test, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/07/2025 Plan of Correction Licensee stated to obtain medical appointment for Resident #3 and Resident #4 to complete the required medical assessment/physician report that includes the tuberculosis (TB) test and submit to LPA Serrano by the plan of correction (POC) due date.

Official classification

Type B

Official code

1569.618(c)(4)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by not ensuring that the toilet by the front door is in good repair which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2025 Plan of Correction Licensee will submit an invoice that a license plumber fixed the toilet by the front door by the plan of correction (POC) due date. .

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the staff has all the training needed to do their job which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2025 Plan of Correction Licensee will submit the staff training for all staff that showed the date that the training was done and the type of training that the staff completed on plan of correction (POC) due date.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review)], the licensee did not comply with the section cited above by not ensuring that resident #4 has the appraisal of of needs and services plan which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2025 Plan of Correction Licensee agreed to submit a letter of understanding of the above mentioned regulation by the plan of correction (POC) due date.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not ensuring that resident #3 and resident #4 has the signed admission agreement on file for review which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2025 Plan of Correction Licensee agreed to submit a copy of the signed admission agreement for resident #3 and resident #4 on plan of correction (POC) due date.

Official classification

Type B

Official code

1569.695(a)(2)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by not ensuring that the facility has the 72 hour emergency food and water which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2025 Plan of Correction Licensee will submit a picture of the 72 hour emergency food and water by the plan of correction (POC) due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not ensuring that the facility has the emergency fire and earthquake drill was done quarterly by all staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2025 Plan of Correction Licensee will submit the fire and earthquake emergency drill completed and signed by all staff on plan of correction (POC) due date.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews and record review, the licensee did not comply with the section cited above by not ensuring that all the staff has the health screening report available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2025 Plan of Correction Licensee will submit a statement of understanding on the above-mentioned regulation by the plan of correction (POC) due date.

Official classification

Type B

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465- Incidental Medical and Dental Care (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.... This requirement was not met as evidenced by: based on interviews and record review the licensee didn't ensure medications were inaccessible to residents in care which pose potential health, safety and personal rights risk to residents in care.

Official plan of correction

The licensee has purchased a lockbox for medications to be stored in the refrigerator. The licensee has also agreed to provide training on the cited regulation & provide a signed statement of understanding by all staff members and provide proof of training by the POC date of 10/2/2024.

Deadline recorded: Oct 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87633(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above by not having an approved hospice waiver for (5) residents; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2024 Plan of Correction The Licensee/Administrator shall read regulation 87632 Hospice waiver and submit to the Licensing Agency a hospice increase waiver request by POC due date.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above by Staff #1, #2, #3 did not have record of tuberculosis results on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/10/2024 Plan of Correction The Licensee/Administrator shall submit to the Licensing agency documentation of staff's tuberculosis results by POC due date.

Official classification

Type B

Official code

87412(a)(1)(2)(3)(5)

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (1) Employee's full name. (2) Social Security number. (3) Date of employment..(5) Home address and telephone number...this requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited by not having record of employment record/application for staff #1, staff#2, staff#3, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/10/2024 Plan of Correction The Licensee/Administrator shall submit to the Licensing Agency documentation of employment record/application by POC due date.

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above by not maintaining record of S3's first aid/CPR and dementia training; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/10/2024 Plan of Correction The Licensee/Administrator shall submit to the Licensing Agency documentation of staff training by POC due date.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above by resident #1 did not have record of a preadmission appraisal on file; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/10/2024 Plan of Correction The Licensee/Administrator shall read and submit a statement of understanding of the cited regulation and submit the statement to the Licensing Agency by POC due date.