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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600382
Report Date: 08/16/2024
Date Signed: 08/16/2024 07:16:34 PM

Document Has Been Signed on 08/16/2024 07:16 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: 19DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Crizaldo Robles/House ManagerTIME VISIT/
INSPECTION COMPLETED:
07:20 PM
NARRATIVE
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On this day, August 16, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Crizaldo Robles, house manager. 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 and 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 yard and backyard. LPA randomly selected 5 bedrooms for inspection. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed 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 109 degrees Fahrenheit. Fire extinguishers checked, observed fully charge with tags showed serviced 4/10/24.

LPA reviewed 5 staff and 5 resident files, and interviewed 1 resident and 1 staff. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Records. Resident's P&I checked and compared with last recorded balance.

LPA observed the following:
-at 3:50 pm, unlocked drawer and cabinet where knives and cleaning supplies were kept.
-at 3:57 pm, expired mustard (expiration: 7/17/23; 3/07/24) and mayonnaise (expiration: 10/11/23)

......continued on 812C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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: 08/16/2024
NARRATIVE
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-at 4:05 pm, oven toaster in one of the residents' rooms
-at 5:00 pm, staff (S3) does not have TB test result on file; LIC503 showed result pending.
-at 5:15 pm, staff (S4) does not have the complete required training on file.
-at 5:20 pm, staff (S5) does not have TB test on file.
-at 5:40, resident's (R3) date of birth on ID and and date of admission on Admission Agreement do match the dates on LIC601.

Administrator to submit copies of the following updated/current documents by August 30, 2024:
1. LIC308 Designation of Facility Responsibilty
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan
4. Proof of Surety Bond coverage

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 violations within 12 month period may result is civil penalties.

Deficiencies, plan and proof of corrections were discussed.

Exit Interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/16/2024 07:16 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/16/2024 at 06:27 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: 08/16/2024

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in unlocked drawer and cabinet where knives and cleaning supplies were kept which posed an immediate health, safety and/or personal rights risks to persons in care.
POC Due Date: 08/17/2024
Plan of Correction
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2
3
4
Staff locked the drawer and cabinet.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 8/17/24.
Type A
Section Cited
CCR
80076(a)
80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in expired mustard and mayonnaise which pose an immediate health risks to persons in care.
POC Due Date: 08/17/2024
Plan of Correction
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2
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4
Staff threw away the items.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 8/17/24.
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: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/16/2024 07:16 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/16/2024 at 06:27 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: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
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: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records rreview, the licensee did not comply with the section cited above in S3 not having TB test result on file (LIC503 showed pending) and S5 no TB test record on file which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 08/31/2024
Plan of Correction
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Administrator to have S3 and S5 TB tested and submit copies of test results by 8/30/24.
Type B
Section Cited
CCR
80065(f)
80065 Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in staff (S4) not having the complete required training which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Administrator to have S4 complete the training and submit proof by 8/30/24.
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: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/16/2024 07:16 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/16/2024 at 06:43 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: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
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:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in resident’s (R3) date of birth on ID and date of admission on Admission Agreement do match the dates on LIC601 which pose a potential personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Administrator to check all residents' records, check for accuracy and correct accordingly including R3's records. Self-certiification to be submitted by 8/30/24.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
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: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


LIC809 (FAS) - (06/04)
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