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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600382
Report Date: 12/12/2024
Date Signed: 12/12/2024 07:54:42 PM

Document Has Been Signed on 12/12/2024 07:54 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: 18DATE:
12/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:45 PM
MET WITH:Kenneth Lal/StaffTIME VISIT/
INSPECTION COMPLETED:
08:00 PM
NARRATIVE
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On this day, 12/12/24, at 5:45 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to the Unusual Incident Report (UIR) and Death Report for resident (R1) submitted by Joseph Crisol, administrator (ADM). LPA met with Kenneth Lal, staff. LPA called and spoke over the phone with ADM and informed the reason for visit.

LPA requested for copies of LIC602A Physician's Report and LIC625 Appraisal/Needs and Services Plan. LPA conducted interviews.

Review of documents showed the following:
1. UIR: on 11/23/24, staff called licensee to report R1 has diarrhea and been going for 3 times in the last 3 hours. R1 was immediately brought to the hospital. R1 was admitted to the facility on 10/02/24.
2. Death Report: prior to R1's death, R1 was brought to the hospital on 11/23/24 for diarrhea where R1 was diagnosed with Clostridium Difficile Colitis (C. diff). R1 condition further deteriorated while at the hospital and passed away on 12/01/24. Certificate of Death showed C. diff as one of primary causes of death.
3. LIC602A Physician's Report dated 9/24/24: primary diagnosis - major neurocognitive disorder due to Alzheimer's with behavioral disturbance. R1 was dependent on others with all activities of daily living (ADLs).

Facility's Description of Operation/Program Plan does not include admitting and/or retaining resident with dementia/Alzheimer's. Facility does not have Dementia Care Plan


.........continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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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: 12/12/2024
NARRATIVE
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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 in civil penalties.

Deficiencies, plan and proof of corrections were discussed with the ADM over the phone. ADM gave permission to Kenneth Lal to sign and receive this report.

Exit Interview conducted. Appeal Right, LIC9098 Proof of Correction form and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2024 07:54 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/12/2024 at 07:17 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: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/26/2024
Section Cited
CCR
85068.4(a)(4)

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85068.4 Acceptance and Retention Limitations
(a) The licensee shall not accept or retain the following: (4)Persons who require more care and supervision than is provided by the facility.
-This requirement is not met as evidenced by:
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Administrator to read the Regulations and submit self-certification by 12/26/24,
In addition, administrator not to admit a person who is dependent with all ALDs.
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-Based on records review and interviews, the licensee did not comply with the section above for admitting R1 who was dependent on others with all ADLs which posed a potential risks.
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Type B
12/27/2024
Section Cited
CCR80022(a)(b)(2)

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80022 Plan of Operation
(b) The plan and related materials shall contain the following: (2) Statement of admission policies and procedures regarding acceptance of clients.

-This requirement is not met as evidenced by:
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Administrator to read the Regulations and submit self-certification by 12/26/24.
Administrator stated he will not admit a person with Alzheimer's/dementia.
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-Based on records review, the licensee did not comply with the section above in admitting R1 who has Azheimer's when facility's Plan of Operation did not include admitting a person with this medical condition and facility does not have Dementia Care Plan which posed a potential risks.
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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: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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