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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600538
Report Date: 05/02/2024
Date Signed: 05/02/2024 11:51:34 AM

Document Has Been Signed on 05/02/2024 11:51 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/
DIRECTOR:		ISABELO C REMIGIOFACILITY TYPE:
735
ADDRESS:8497 GALINDO DRIVETELEPHONE:
(925) 828-0452
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 6CENSUS: 5DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:03 AM
MET WITH:ISABLEO REMIGIO, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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On 5/02/2024 at 10:00 AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Isabelo Remigio and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 114.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 04/16/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 3/16/2024.

Report continues on 809 C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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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 II
FACILITY NUMBER: 015600538
VISIT DATE: 05/02/2024
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Continue from LIC 809

LPA reviewed 3 of 5 residents records. LPA reviewed 4 of 8 staff records and 4 of 8 have current first aid training and associated to the facility. LPA reviewed a sample of 5 of 5 resident’s medications.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC809 (FAS) - (06/04)
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