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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600382
Report Date: 02/01/2023
Date Signed: 02/01/2023 06:31:03 PM

Document Has Been Signed on 02/01/2023 06:31 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
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: 19DATE:
02/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Susan Martinez/Licensee. and
Joseph Crisol/Administrator 		TIME COMPLETED:
05:30 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 a case management inspection in regards to the Death Report and Unusual Incident Report (UIR) submitted by the facility, and received by the Department on January 26, 2023 and January 4, 2023 respectively. Reports indicated that resident (R1) was observed with labored breathing on January 4, 2023. 9-1-1 was called, and R1 was sent out. R1 was admitted to ICU where R1 eventually passed away. Report indicated that the cause of death given by the ICU Department was Acute Respiratory Failure.

On this day, February 1, 2023, LPA met with Crizaldo Robles, care staff. LPA called and spoke with Joseph Crisol, administrator, and informed the reason of visit. The administrator and licensee arrived after about an hour.

LPA conducted interviews. Two staff indicated prior to the incident of R1 being sent out, they observed R1 didn't have appetite and was not eating for about 2 or 3 days, LPA verified and these 2 staff stated they did not report to the administrator.

LPA requested for the following documents to be submitted by Wednesday, February 8, 2023: LIC602 Physician's Report; Appraisal and Re-appraisal; doctor's visit notes

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2023
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 2
Document Has Been Signed on 02/01/2023 06:31 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/01/2023 at 06:00 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOD'S GRACE
FACILITY NUMBER: 015600382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2023
Section Cited
CCR
85075.4(a)

1
2
3
4
5
6
7
85075.4 Observation of the Client
(a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning.

-This requirement is not met as evidenced byL
1
2
3
4
5
6
7
Administrator to in-service the staff and submit proof by 2/02/23.
8
9
10
11
12
13
14
-Based on interviews, the licensee did not comply with the section above when staff did not inform the administrator and/or licensee of the change on R1's condition which posed immediate health risk to person in care.


8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2