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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800107
Report Date: 06/18/2026
Date Signed: 06/18/2026 02:31:11 PM

Document Has Been Signed on 06/18/2026 02:31 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AMAZING GRACE CARE SERVICES LLCFACILITY NUMBER:
331800107
ADMINISTRATOR/
DIRECTOR:		MOJICA, FLORENCE AFACILITY TYPE:
740
ADDRESS:43 SITARA STREETTELEPHONE:
(310) 592-5338
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 6CENSUS: 5DATE:
06/18/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Teresa Espinoza, House managerTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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On 6/18/2026, Licensing Program Analyst (LPA) E. Conchas made an unannounced visit to the facility. The purpose of the visit was to conduct the required comprehensive annual inspection. LPA met with House manager Teresita Espinoza and was granted entry to the facility. At the time of the visit there were two (2) staff present, and four (4) residents present.

The facility is five (5) bedrooms, three (3) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) ambulatory of which four (4) can be non-ambulatory, two (2) hospice care waiver and the current census is five (5) residents. LPA was accompanied by a staff to conduct a general overall inspection, which included, but was not limited to the following:

There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees F. LPA inspected resident bedrooms in which they are equipped with the required furniture. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the restrooms to be at 140 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. One (1) fire extinguisher was observed at the facility. LPA observed the facility license, facility administrator, personal rights, the CCLD complaint poster, facility sketch and the ombudsman posted in a common area.

Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine cabinet with the resident’s medications locked. LPAs observed first aid kit and first aid book at the facility.

Continue to LIC809C

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2026
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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Document Has Been Signed on 06/18/2026 02:31 PM - It Cannot Be Edited


Created By: Edith Conchas On 06/18/2026 at 01:39 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: 06/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(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
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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.
POC Due Date: 06/19/2026
Plan of Correction
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Licensee will have the residents obtain a TB test notify LPA when completed by POC, than send a copy of the results to LPA
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/18/2026 02:31 PM - It Cannot Be Edited


Created By: Edith Conchas On 06/18/2026 at 01:39 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: 06/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(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
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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.
POC Due Date: 06/19/2026
Plan of Correction
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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
Type B
Section Cited
CCR
87465(e)(2)
Incidental Medical and Dental Care Services
(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
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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.
POC Due Date: 06/18/2026
Plan of Correction
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Licensee to create a policy on charting errors and conduct a training with staff on charting errors.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/18/2026 02:31 PM - It Cannot Be Edited


Created By: Edith Conchas On 06/18/2026 at 01:39 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: 06/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(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
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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.
POC Due Date: 07/09/2026
Plan of Correction
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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
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AMAZING GRACE CARE SERVICES LLC
FACILITY NUMBER: 331800107
VISIT DATE: 06/18/2026
NARRATIVE
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Seven (7) days’ supply of non-perishable foods and two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

The facility has enough staff to provide care and supervision to the residents in care. Also, LPA observed that the facility has a dementia resident.

LPA reviewed resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA observed the residents centrally stored medications and MAR.

LPA reviewed staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

The following was observed and cited

· Type B was issued. LPA observed two (2) resident restrooms where the water measured at a temperature of 140 degrees F.

· Type B. LPA observed one (1) resident MAR (R5) that was initialed by staff indicating the medication was given during the time the R5 was not at the facility.

· Type B. LPA observed R1, R3 and R5 appraisals to be incomplete.

· Type A. LPA observed R1 and R3 to not have their TB completed.

Based on the observations made during today’s visit, four (4) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report and Appeal Rights were discussed and provided to House Manager, Teresita Espinoza.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026
LIC809 (FAS) - (06/04)
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