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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 10:54:39 AM

Document Has Been Signed on 05/09/2022 10:54 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Isabelo C Remigio, Administrator TIME COMPLETED:
11:04 AM
NARRATIVE
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On 05/09/2022 at 10:05 AM Licensing Program Analysts (LPAs) J. Clancy-Czuleger and K. Nguyen opened a Case Management. LPA met with Isabelo C Remigio, Administrator.

While at the facility for infection control inspection LPAs observed that the floor plan and current room occupancies did not match up.


The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
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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Document Has Been Signed on 05/09/2022 10:54 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 05/09/2022 at 10:23 AM
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 II
FACILITY NUMBER: 015600538

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2022
Section Cited
CCR
80020(a)

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All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidence by:
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Licensee has agreed to submit a updated facility sketch and STD 850 to CCLD by POC date.
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Based on observation, licensee failed to comply with fire clearance. Facility sketch approved by the fire department did not match the current layout of the facility and was converted into two staff rooms which poses an immediate safety risk to the clients in care.
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Civil penalty of $500 was assessed for fire clearance violation.

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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022


LIC809 (FAS) - (06/04)
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