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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600382
Report Date: 08/11/2023
Date Signed: 08/11/2023 06:48:00 PM

Document Has Been Signed on 08/11/2023 06:48 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:
08/11/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Crizaldo Robles/Staff TIME COMPLETED:
06:50 PM
NARRATIVE
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At 4:20 pm on this day, August 11, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced, and met with Crizaldo Robles, staff, and informed the reason for visit. LPA sent message to Joseph Crisol, administrator. Administrator can not come to the facility, ad authorized Crizaldo Robles to sign and receive this report.

LPA reviewed 5 residents records and interviewed 3 residents. P&I records reviewed. Medications were checked and compared with doctor's orders and records.

LPA received copies of the following updated documents:
1. LIC308 Designation of Facility Responsibility
2. LIC610D Emergency Disaster Plan (9 pages)
3. LIC500 Personnel Report

At 5:55 pm, LPA observed resident's (R1, R2, R3, R4 and R5) LIC622 Centrally Stored Medication and Destruction Records not complete - the expiration dates and dates medications started were blank.

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.

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: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023
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 08/11/2023 06:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/11/2023 at 06:32 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: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
870075(k)(7)(F)
80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:
(F) Expiration date

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records, review, the licensee did not comply with the section cited above in 5 out 5 residents' LIC622 Centrally Stored Medication and Destruction Records not completely filled-up which pose a potential personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Administrator to check all the LIC622s, and submit by 8/25/23 a self-certiication documents are all completely filled-up.
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: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023


LIC809 (FAS) - (06/04)
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