<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600382
Report Date: 07/27/2021
Date Signed: 07/27/2021 05:29:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GOD'S GRACEFACILITY NUMBER:
015600382
ADMINISTRATOR:JOESEPH G CRISOLFACILITY TYPE:
735
ADDRESS:629 HAMPTON ROADTELEPHONE:
(510) 278-3607
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:23CENSUS: 20DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Sally Espina/House ManagerTIME COMPLETED:
05:35 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 Analyst (LPA) Delmundo arrived unannounced to conduct an annual required/infection control inspection. LPA met with Sally Espina, house manager, and informed the purpose of LPA's visit. LPA also called Susan Martinez, licensee, who indicated she can not come to the facility and gave permission to have Sally Espina sign and receive this report.

LPA toured the facility inside out with Sally Espina. LPA inspected the reception and dining areas, kitchen, bathrooms and shower room, front and side yards, and backyard. LPA randomly selected 6 bedrooms (#'s 3, 5, 8, 12, 9 and 10) for inspection. Medications are centrally stored in a locked area that is inaccessible to residents and medications are refilled every two weeks. LPA observed food supplies for 2 days of perishables and 7 days of non-perishables.

LPA observed COVID-19 signage. Facility has hand sanitizer, surgical masks, face shields and gloves available by the visitor's entrance door. Staff screen visitors prior to allowing entry. Facility has visitor's log. LPA inspected the supplies of Personal Protective Equipments (PPEs) including but not limited to N95 respirators, surgical masks, disposable gloves, hand sanitizers, face shields. Facility has a copy of approved LIC808 Mitigation Plan on file.

Hot water temperature in one of the bathrooms was tested and measured at 111.2 degrees Fahrenheit. Fire extinguishers checked, observed fully charge with tags showed serviced April 19, 2021.


......continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/27/2021
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
The following updated documents to be submitted by August 10, 2021:
1. LIC500 Personnel Report
2. LIC610D Emergency Disaster Plan

LPA observed the following:
1. Backyard: broken wheelchairs, walkers, steel cabinet, TV, cassette layer; worn out/soiled mattresses; old steel chair; car seat; bathroom sink; pieces of wood; screen window; lamp
2. Trash bins with no lids.
3. N95 respirators not sufficient for 30 days and no supply of disposable gowns.
4. No N95 fit testing record for staff. LPA verified and Susan Martinez stated they haven't conducted fit testing.
5. Visitor's poster outdated and no hand washing and cough/sneeze etiquette posters.
6. PPEs are on several locations (2 separate storage) and staff having difficulty finding/locating them.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). 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 Susan Martinez over the phone in the presence of Sally Espina.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, 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. LPA observed the following in the backyard: broken wheelchairs, walkers, steel cabinet, TV, cassette layer; worn out/soiled mattresses; old steel chair; car seat; bathroom sink; pieces of wood; screen window; lamp. LPA also observed trash bins with no lids
POC Due Date: 08/10/2021
Plan of Correction
1
2
3
4
Licensee to do the following and submit pictures by 8/10/2021:
1. Have the backyard cleaned.
2. Purchase trash bins (step--on) with lids.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4