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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600382
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:00:54 PM

Document Has Been Signed on 01/25/2024 02:00 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: 22DATE:
01/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Joseph Crisol/AdministratorTIME COMPLETED:
02:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to the Unusual Incident Report (UIR) for resident (R1) submitted by the administrator.on 1/22/24. LPA met with Joseph Crisol, administrator, and informed the reason for visit.

LPA obtained and reviewed R1's LIC602 Physician's Report, LIC625 Appraisal/Needs and Services Plan, LIC601 Identification and Emergency Contact Information and conservatorship document.

UIR indicated the following: in the afternoon of 1/20/24, staff noticed R1 was not in his room and common areas. Staff took the company car and search for R1. The other staff filed a report to local law enforcement and notified the administrator. R1 was found by local law enforcement in Contra Costa County the following day, 1/21/24. Administrator picked-up and brought R1 back to the facility.

On this day, 1/25/24. LPA conducted inspection and interviews. LPA observed all entrance/exit doors without and R1's room's exit door leading to the side yard without auditory signals and LIC625 not updated to include on the care plan the AWOL behavior.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with the administrator.

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: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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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Document Has Been Signed on 01/25/2024 02:00 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/25/2024 at 12:57 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: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2024
Section Cited
CCR
80077.3(a)

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80077.3 (a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to
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Administrator to do the follwoing and submit proof by 1/26/24:.
1. Install auditory signals and submit pictures.
2. In-service the staff and submit copy of training topic with attendees signatures.
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...alert staff when the door is opened.
-This requirement is not met as evidenced by:
-Based on observation and interview. the licensee did not comply with the section above for not installing an auditory signal when R1 was identified to have AWOL behavior which pose an immediate risk.
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Type B
02/08/2024
Section Cited
CCR85068.3(a)

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85068.3 Modifications to Needs and Services Plan: (a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or....
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Administrator to update the LIC625 and submit copy by 2/08/24.
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...... social functioning.
-This requirement is not a evidenced by:
-Based on interview and record review, the licensee did not comply with the section above for not updating R1's LIC625 after R1 AWOLed which poses a potential safety risks to persons in care.
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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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
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