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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600538
Report Date: 05/09/2022
Date Signed: 05/09/2022 10:03:38 AM

Document Has Been Signed on 05/09/2022 10:03 AM - 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 GRACE IIFACILITY NUMBER:
015600538
ADMINISTRATOR:ISABELO C REMIGIOFACILITY TYPE:
735
ADDRESS:8497 GALINDO DRIVETELEPHONE:
(925) 828-0452
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 6CENSUS: 4DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH: Isabelo C Remigio, Administrator TIME COMPLETED:
10:03 AM
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On 5/9/22 at 8:40am, Licensing Program Analysts (LPAs) K. Nguyen and J. Clancy-Czuleger arrived unannounced to conduct Infection Control Inspection. LPAs tour the facility with Herjalyn Tillah staff, and explained the purpose of the visit. Administrator, Isabelo C Remigio later arrived at 9:05am.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, four bedrooms, 2 bathroom, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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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