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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600382
Report Date: 07/12/2023
Date Signed: 07/12/2023 05:07:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/10/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230710104024
FACILITY NAME:GOD'S GRACEFACILITY NUMBER:
015600382
ADMINISTRATOR:JOSEPH G CRISOLFACILITY TYPE:
735
ADDRESS:629 HAMPTON ROADTELEPHONE:
(510) 278-3607
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:23CENSUS: DATE:
07/12/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Susan Martinez/LicenseeTIME COMPLETED:
05:05 PM
ALLEGATION(S):
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Facility staff did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegatiion. LPA met with Susan Martinez, licensee, and informed the reason for visit. LPA spoke over the phone with Joseph Crisol, administrator.

During the course of investigation, LPA reviewed residents' files, interviewed staff and residents, and obtained copies of residents' records.

Resident (R1) stated he was feeling weak and called for help, heard footsteps coming to his room then passed out in the afternoon of July 7, 2023. When he gained consciousness, the staff told him his blood pressure was high. He was feeling weak still and was only brought to hospital early morning of July 8, 2023.

....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
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 3
Control Number 15-AS-20230710104024
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOD'S GRACE
FACILITY NUMBER: 015600382
VISIT DATE: 07/12/2023
NARRATIVE
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LPA interviewed staff (S1, S2, S3 and S4). Three out of 4 staff stated R1's blood pressure was high on the time R1 called for help on July 7, 2023, was observed weak and was found on the floor; however, they did not call 9-1-1. The staff only called 9-1-1 when R1 called for help the second time around 3:00 am the following day and R1 was taken to the hospital by the first responders.

Based on LPA's records review and interviews, the preponderance of evidence has been met, therefore the allegation of 'Facility staff did not seek medical attention in a timely manner' is found to be substantiated. Title 22 California Code of Regulations is being cited and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violations within 12 month period may result in civil penalties.

Deficiency and plan and proof of correction were discussed with the licensee.

Exit interview conducted. Copy of this report, LIC9098 Proof of Correction form and Appeal Rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20230710104024
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOD'S GRACE
FACILITY NUMBER: 015600382
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2023
Section Cited
CCR
80075(a)
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80075 Health Related Services
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services
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Licensee to do the following:'.
1. Revisit facility's medical emergency protocol.
2. in-service the staff, and submit copy of training topic with attendees signatures by 7/13/23.
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-This requirement is not met as evidenced by:

-Based on interview and records review, the licensee did not comply with the section above when staff didn't seek immediate medical attention when R1 was found on the floor and bp was high.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3