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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601191
Report Date: 04/30/2024
Date Signed: 04/30/2024 12:10:55 PM


Document Has Been Signed on 04/30/2024 12:10 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:GRACE HOME CAREFACILITY NUMBER:
015601191
ADMINISTRATOR:DEL ROSARIO, GRACEFACILITY TYPE:
740
ADDRESS:17121 VIA ALAMITOSTELEPHONE:
(510) 317-7548
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY:6CENSUS: 0DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Grace Del RosarioTIME COMPLETED:
11:45 AM
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On 04/30/2024 at 11:15 AM, Licensing Program Analyst (LPA) Lori Alexander arrived announced to conduct 1-Year Annual Required inspection. LPA met with Licensee/Administrator, Grace Del Rosario and explained the purpose of the visit. The facility’s fire clearance was approved for six (6) in which all may be non-ambulatory and hospice waiver for two (2). Administrator certificate # 6020400740 expires 09/14/2024. There are currently no residents at the facility

LPA toured facility with Grace including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are occupied by the residents and 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 61 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024
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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