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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600382
Report Date: 07/28/2023
Date Signed: 07/28/2023 06:51:01 PM

Document Has Been Signed on 07/28/2023 06:51 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: 22DATE:
07/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Crizaldo Robles/Staff and
Joseph Crisol/Administrator		TIME COMPLETED:
07:00 PM
NARRATIVE
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On this day, July 28, 2023, at 2;50 p.m, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with LPA met with Crizaldo Robles, staff. LPA called and spoke over the phone with Joseph Crisol, administrator, and informed the reason for visit. Administrator authorized Crizaldo Robles to be with LPA during inspection. Administrator arrived at 4:00 pm and has to leave. Administrator authorized Crizaldo Robles to sign and receive this report.

Facility has LIC9282 Infection Control Plan.

LPA toured the facility inside out. LPA inspected the dining room. kitchen, receiving area, bathrooms/shower rooms, side and backyards. LPA randomly selected 6 bedrooms for inspection. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was locked.

Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in one of the bathrooms was tested, and measured at 112.6 degrees Fahrenheit..

LPA reviewed 5 staff files, and interviewed 3 staff.

LPA observed the following:
-at 3:04 pm, medications, Lysol and peritoneal cleanser in one of the residents' rooms.
-at 3:13 pm, window screen in one of the residents bedrooms ripped and bent.
-at 4:20 pm, no record of disaster drill.
-at 4:55 pm. staff's (S2) First Aid/CPR certificate expired 4/2023.
-at 5:00 pm. staff (S3) has no First Aid/CPR and health screening record on file.

,.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: 07/28/2023
NARRATIVE
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=Administrator to submit the following updated documents by August 11, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC610D Emergency Disaster Plan (9 pages)
3. LIC500 Personnel Report

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 violation within 12 month period may result in civil penalties.

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

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: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/28/2023 06:51 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/28/2023 at 05:56 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: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for Lysol and peritoneal cleanser in resident's room which pose immediate safety risks to persons in care.
POC Due Date: 07/22/2023
Plan of Correction
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Staff locked the items.
Administrator to in-service the staff, and submit copy of training topic with attendees signatures by 7/29/23.
Type A
Section Cited
CCR
80075(j)(3)
80075 Health Related Services
(j) Medications shall be centrally stored under the following circumstances:
(3) Because of physical arrangements and the condition or the habits of persons in the facility, the medications are determined by either the administrator or by the licensing agency to be a safety hazard


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 for unlocked medications in the resident's room which which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 07/29/2023
Plan of Correction
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Staff locked the items.
Administrator to in-service the staff, and submit copy of training topic with attendees signatures by 7/29/23.
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: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/28/2023 06:51 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/28/2023 at 05:56 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: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 for ripped and bent window screen in one of the residents rooms which poses poses a potential personal rights risk to persons in care.
POC Due Date: 08/11/2023
Plan of Correction
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Adninistrator stated he'll have screen replaced. Picture to be submitted by 8/11/23.
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 staff without health screening record on file which poses a potential health risk to persons in care.
POC Due Date: 08/11/2023
Plan of Correction
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Adminstrator to have the staff screen, and submit document by 8/11/23.
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: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/28/2023 06:51 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/28/2023 at 05:56 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: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee did not comply with the section cited above in 1 staff not having first aid record on file and one is expired which pose a potential safety risk to persons in care.
POC Due Date: 08/11/2023
Plan of Correction
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Administrator to have the staff certified, and submit proof by 8/11/23.
Type B
Section Cited
CCR
80023(d)(2)
80023 Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.
(2) The drills shall be documented and the documentation maintained in the facility for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for not having dissater drill records on file which poses a potential safety risk to persons in care.
POC Due Date: 08/11/2023
Plan of Correction
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Administrator to conduct drills, and submit proof by 8/11/23.
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: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
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