015600382-9-14-2023-15-AS-KHOS-CVZR5R-20230925124335

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600382
Report Date: 09/14/2023
Date Signed: 09/14/2023 02:57:02 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/06/2023 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20230906121905

FACILITY NAME:	GOD'S GRACE		FACILITY NUMBER:	015600382
ADMINISTRATOR:	JOSEPH G CRISOL		FACILITY TYPE:	735
ADDRESS:	629 HAMPTON ROAD		TELEPHONE:	(510) 278-3607
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	23	CENSUS: 20	DATE:	09/14/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Susan Martinez/Licensee		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff (S1) made inappropriate comments to resident (R1).

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with staff, Bernard Corpus, who called the licensee, Susan Martinez. Licensee arrived after several minutes, and LPA informed the reason for visit. LPA also met with other staff, Kenneth Lal and James Andrew Cabigon.

It was alleged that resident (R1) was having a normal conversation with staff (S1) when S1 asked R1 of R1's height and told R1 the size of R1's private part relative to R1's height. S1 continued by telling R1 about S1's height and the size of private part relative to his height.

LPA conducted interviews, reviewed the Usual Incident Report submitted by the facility, and obtained copy of facility's internal investigation.

.....continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 15-AS-20230906121905

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/14/2023

NARRATIVE

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R1 stated that S1 told R1 that R1's height is about 5 feet 9 inches and that R1's private part size is 6 inches. R1 further stated that S1 told R1 that since S1 is about 5 feet, the size of S1's private part is 4 inches.

LPA interviewed S1 and S2. S1 denied telling R1 of the size of R1's private part relative to R1's height but stated R1 told S1 about R1's height and he told R1 that R1 is blessed. S1 confirmed he told R1 that he is about 5 feet tall but his private part is not shrinking. S2 confirmed the incident happened and stated hearing the conversation between R1 and S1 about the sizes of their private parts relative to their heights.

Based on interviews and record review, the preponderance of evidence has been met, therefore the allegation is found to be substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Deficiency and plan and proof of correction were discussed with licensee. Licensee has to leave, and authorized James Andrew Cabigon to sign and receive this report.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230906121905

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/28/2023 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	80072 Personal Rights : (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.	1 2 3 4 5 6 7	Licensee and/or administrator to in-service the staff, and submit copy of training topic with attendees signatures by 9/28/23.
	8 9 10 11 12 13 14	-This requirement is not met as evidenced by: -Based on interviews and records review, the licensee did not comply with the section above for S1 making inappropriate comments to R1 which posed personal rights risk to person in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC9099 (FAS) - (06/04)

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