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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600382
Report Date: 06/26/2024
Date Signed: 06/26/2024 04:43:34 PM

Document Has Been Signed on 06/26/2024 04:43 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/
DIRECTOR:		JOSEPH G CRISOLFACILITY TYPE:
735
ADDRESS:629 HAMPTON ROADTELEPHONE:
(510) 278-3607
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 23CENSUS: 21DATE:
06/26/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Joseph Crisol/Administrator TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On this day, June 26, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20240620142927). LPA met with Joseph Crisol. administrator, and informed the reason for visit.

LPA toured the facility inside out with the administrator. LPA inspected the common areas, sitting/reception area, dining room, kitchen, bathrooms/shower rooms, front, side and backyards. LPA randomly selected 7 bedrooms for inspection.

LPA observed the following:
-at 3:30 p.m., Febreze freshner in the residents' room.
-at 3:48 p.m., shovel in the backyard.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. A $250,00 civil penalty is assessed for repeat violation of section 80087(g) within 12 month period. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiency, plan and proof of correction and civil penalty were discussed with the administrator,

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment and LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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 06/26/2024 04:43 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/26/2024 at 04:00 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: 06/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2024
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
-This requirement is not met as evidenced by:
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Administrator locked the items.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 6/27/24.

A $250.00 civil penalty is assessed on this day.
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-Based on observation, the licensee did not comply with the following unlocked items which pose an immediate risks to persons in care: shovel in the backyard; Febreze in the residents' room
This is a repeat violation within 12-month period. First citation was issued on 7/28/23.
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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: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
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