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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600382
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:57:03 PM

Document Has Been Signed on 09/15/2022 02:57 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: 20DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Crizaldo Robles/Care StaffTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with Crizaldo Robles, care staff, and informed the purpose of visit. LPA called and spoke with Joseph Crisol, administrator. Administrator stated he can not come to the facility to meet LPA so he authorized Robles to sign and receive this report.

Facility has an approved LIC808 Mitigation Plan on file. Administrator has not submitted the new Infection Control Plan.

LPA toured the facility inside out with Robles. LPA inspected the common area, dining room, kitchen, hallways, bathrooms. shower room, side and backyard. LPA randomly selected 7 bedrooms for inspection. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer, no touch temperature probe and Visitor's Log. Visitor's temperature and symptom checks are done at the entrance. Residents and staff are screened for COVID-19 symptoms, and temperature checked and recorded daily. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs checked and observed adequate for 30 days, and antigen test kits are readily available. Trash bins were observed with foot pedal operated lids. Bathroom lavatories were observed with liquid soap and paper towels in dispensers. Staff were fit tested or N95 respirator last year, August 10, 2021. LPA verified, and administrator stated re-certification is scheduled for September 19, 2022.
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SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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: 09/15/2022
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Fire extinguishers checked and observed fully charge with tags showed serviced April 21, 2022. Hot water temperature in one of the common bathrooms was tested and measured at 117.8 degrees Fahrenheit.

LPA observed the following:
1. No hand washing posters in 2 bbathrooms. Broken faucet handle in one of these bathrooms,
2. Dilapidated baseboards, missing baseboard near the common bathroom, chipped wall paint, chipped laminate flooring in room #'s 8 and 12.
3. Bedframe, worn out mattress, rusted wheel barrow, old industrial fan, broken chair, empty cleaning agent container in the backyard
4. Walnut fruits that fell from the tree in the backyard were scattered on the backyard ground.

The following updated/current documents to be submitted by September 29, 2022:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Infection Control Plan
5. N95 Fit Testing Records

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the administrator over the phone.

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: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2022 02:57 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/15/2022 at 02:26 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: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.


This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The following were observed: broken bathroom faucet handle; chipped and missing baseboards; chipped wall paint; chipped flooring in 2 residents' rooms; bed frame, worn out mattress, rusted wheel barrow, old industrial fan, broken chair, empty cleaning agent container, scatterred walmut seeds in the backyard which pose potential safety and personal right risks to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Administrator to do the following and submit pictures by 09/29/2022:
1. Have the backyard cleaned.
2. Install baseboard and repaint. Repaint the wall.
3. Replace the flooring and install new faucet handle.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
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