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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600382
Report Date: 08/16/2024
Date Signed: 08/16/2024 07:04:18 PM

Document Has Been Signed on 08/16/2024 07:04 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: 19DATE:
08/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Crizaldo Robles/House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On this day at around 12:15 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to the Death Report for resident (R1) submitted by Joseph Crisol, administrator. LPA met with house manager, Crizaldo Robles, and explained the purpose of the visit. LPA called and spoke over the phone with the administrator. Administrator stated he can not come to the facility, and authorized the house manager to sign and received this report.

Death report indicated that R1 passed away on 8/12/24 at approximately 8:10 am. Staff did not notice anything out of the ordinary with R1 prior to R1's death. Staff also did not notice any changes in condition day prior to R1's death. When staff was calling residents for breakfast, R1 was observed not responding. 9-1-1 was called immediately. The first responder and deputies declared R1 deceased. The administrator called and informed R1's family member (FM).

LPA obtained copies and reviewed the following: LIC601 Identification and Emergency Contact Information; Appraisal/Needs and Services Plan; doctor's order of medications; Medication Administration Record; Physician's Visit Forms; LIC622 Centrally Stored Medication and Destruction Record. LPA interviewed staff and FM, and checked the medications.

LPA observed the following:


1. Medications were pre-poured.
2. Quantity of 1 medication remaining not consistent with what should be based on the start date recorded on LIC622. The medication with 90 quantity filled on 5/22/24 has remaining 72 tablets when should be 48 based on date the medication started 7/01/24.
3. LIC622 not completely filled-up; some do not have record of quantity received and strength.

....continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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 08/16/2024 07:04 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/16/2024 at 03:23 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: 08/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2024
Section Cited
CCR
80075(b)

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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

-This requirement is not met as evidenced by:
-Based on records review, the licensee...
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Administrator agreed to have the staff trained by a vendorized trainer, and submit proof by 8/17/24.
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....did not comply with the section above for R1's medications at facility's hand not consistent with what should be remaning based on LIC622. It's not clear if the medication was properly administered which posed an immediate health risk to person 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: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/16/2024 07:04 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/16/2024 at 03:28 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: 08/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2024
Section Cited
CCR
80075(k)(6)

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80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(6) No medications shall be transferred between containers.

-This requirement is not met as evidenced by:
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Administrator to in-service the staff and submit proof by 8/30/24.
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-Based on records review, the licensee did not comply with the section above for pre-pouring of medications which posed a potential health and/or personal rights risks to person in care.
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Type B
08/30/2024
Section Cited
CCR80070(a)

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80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

-This requirement is not met as evidenced by
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Administrator to add to in-service and submit proof by 8/30/24.
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-Based on records review, the license did not comply with the section above for not having R1's LIC622 completely filled-up which posed a potential personal right risk to person 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: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


LIC809 (FAS) - (06/04)
Page: 3 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: 08/16/2024
NARRATIVE
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Page 2

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violations within 12 month period may result is civil penalties.

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

Exit Interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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