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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600382
Report Date: 03/12/2025
Date Signed: 03/12/2025 04:02:41 PM

Document Has Been Signed on 03/12/2025 04:02 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:
03/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Kenneth Lal/Staff TIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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On this day, 3/12/25, at 11:40 am, 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 facility on 2/28/25 for incident that occurred on 2/27/25. LPA met with Kenneth Lal, staff. LPA called and spoke over the phone with Joseph Crisol, administrator (ADM) and informed the reason for visit.

UIR indicated that on 2/27/25, a neighbor and a driver passing by informed the staff that R1 has assaulted an individual (ML) on the street. The neighbor, driver and ML informed the staff how R1 groped ML's breast while on the street. Staff called 9-1-1. Sheriffs arrived and arrested R1.

LPA reviewed R1's file and obtained copies of including but not limited to the following: LIC602 Physician's Report; LIC625 Appraisal/Needs and Services Plan; Unusual Incident Reports (UIRs) for 2024 and 2025. LPA also reviewed all UIRs for 2024 and 2025 in the Community Care Licensing's (CCL) e-fax folder for facility, and conducted interviews.

Review of other R1's UIRs showed the following:
1) UIR: on 1/29/25, a fellow resident (R2) informed staff (S1 and S2) that R1 went across the street. Staff went around the block but could not find R1. R1 then appeared in a curb from the house across the street. The neighbor appeared startled from R1 presence in their backyard and Sheriff was called. R1 has prior groping incident and not allowed by Sheriffs to leave the facility after the 2024 incident. This UIR was not submitted by the facility to CCL nor received by LPA.
2) UIR: on 9/22/24, Sheriff Deputy came to notify the facility that R1 has been arrested for groping a woman on the street. This UIR was not submitted by the facility to CCL nor received by LPA.

.........continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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: 03/12/2025
NARRATIVE
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3) UIR 2/21/25 to 2/24/25: on 2/21/25 at approximately 6:30 am, R1 snuck out of the facility before shift change. The Sheriff came to tell the staff that R1 was arrested for violating his court order to stay in the facility. R1 was then released the next day without notifying the facility and R1 became a missing person. R1 was found Monday, 2/24/25 at a gasoline station in other city.

During interview, ADM stated that the staff (S3) was informed by the Sheriff on 2/21/25 that R1 was arrested for violating the order to stay in the facility.

S1 stated he was at the facility at the time of the incident that happened on 1/29/25. S1 also stated that he was also at the facility when the 2/27/25 incident occurred but didn't personally observed the groping, but staff (S2) told him about it.

LPA interviewed ML who confirmed ML was groped by R1. ML further stated that the neighbor and S2 called the Sheriff.

Review of LIC625 dated 7/22/24 showed R1 must be monitored and redirected to prevent behaviors. ADM did not update the LIC625 when R1 was ordered to stay in the facility when incidents happened after 7/22/24.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for deficiency section 80070(a) for repeat violation within 12 month period. Failure to submit proof of corrections by plan of correction due dates may result in additional 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, LIC421FC Civil Penalty Assessment, 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: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/12/2025 04:02 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/12/2025 at 02:27 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: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2025
Section Cited
CCR
800773.1(a)

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80077.3 Care for Clients Who Lack Hazard Awareness or Impulse Controll
(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 alert
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Administrator to have a buzzer installed and submit picture by 3/13/25.
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staff when the door is opened. The fencing and devices must not substitute for appropriate staffing.
-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above when R1 was able to leave the facility due to the gate/fence not having auditory signal.
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Type A
03/13/2025
Section Cited
CCR80078(a)

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80078 Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

-This requirement is not met as evidenced by:
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Administrator to do the following and submit POC by 3/13/25:
1. Will read the Regulation and submit sef-certification,
2. In-service the staff to ensure proper supervision/care needs of the residents are provided.
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-Based on record review and interviews, the licensee did not comply with the section above when R1 was able to leave the facility and engaged in inappropriate behaviors.
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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: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/12/2025 04:02 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/12/2025 at 02:34 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: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2025
Section Cited
CCR
80061(b)

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80061 Reporting Requirements:
(b) Upon the occurrence, during the operation of the facility, of any of the events..... a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
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Administrator to submit the incident reports and in the future, ensure timely submission. POC to be submitted by 3/26/25.
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-This requirement is not met as evidenced by:
-Based on records review, the licensee did not comply with the section above in not submitting UIRs for 9/22/24 and 1/29/25 which posed a potential health, safety and/or personal rights risks to person in care.
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Type B
03/26/2025
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 obtain the document and submit copy by 3/26/25.

A $250.00 civil penalty is assessed.
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-Based on record review and interview, the license did not comply with the section above for not having the Court Order in R1's file which posed a potential safety and/or personal rights risk to person in care.
This is a repeat violation. A citation was issued on 8/16/24.
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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: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/12/2025 04:02 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/12/2025 at 03:16 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: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2025
Section Cited
CCR
85068.3(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 3/26/25.
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... social functioning.

-This requirement is not met as evidenced by:
-Based on record review and interview, the licensee did not comply with the section in not updating R1's LIC625.
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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: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


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