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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600382
Report Date: 07/17/2024
Date Signed: 07/17/2024 03:18:30 PM


Document Has Been Signed on 07/17/2024 03:18 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



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: 21DATE:
07/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Crizaldo Robles, House ManagerTIME COMPLETED:
03:40 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
On this day at around 2:35pm, Licensing Program Analyst (LPA) K. Nguyen arrived at the facility unannounced to conduct a case management. LPA met with house manager, Crizaldo Robles, and explained the purpose of the visit. Administrator, Joseph Crisol was not available during the visit but gave verbal permission for house manager to sign the report.

LPA received two SIR regrading resident AWOL, and resident being bully by a staff. LPA reviewed resident physician report indicated that this resident could leave facility without assistance. LPA reviewed resident medication list and MAR that during the time of the incident resident was med compliance. House manager indicated that there was no change in resident behavior or any sign of change in condition. LPA interview resident and he indicated that he doesn’t want to stay here just want to be in a co-ed facility, and really want to have a water fountain in the facility. LPA spoke with resident indicated that no staff nor any staff bullied him or being mean to him. Resident return back to the facility, and house staff made aware to continue to encourage resident to come back to the facility every time when resident leaves.

No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
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 1