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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 12:12:06 PM


Document Has Been Signed on 04/30/2024 12:12 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:Case Management - OtherANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Grace Del RosarioTIME COMPLETED:
12:25 PM
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On 04/30/2024 at around 11:45 AM, Licensing Program Analyst (LPA) Lori Alexander arrived to conduct a Case Management Closure visit and met with Licensee Grace Del Rosario.

During the visit, LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining area, living area and garage. LPA observed that the home was being renovated. There were no clients observed at the facility. Licensee stated that she had 4 residents. Licensee states that two (2) residents moved to her sister facility location in Livermore, CA . Licensee stated that the other 2 residents moved to 2 separate facilities located in Hayward, CA.

Licensee stated that she originally faxed notification to Community Care Licensing Division (CCLD) on March 27, 2024 regarding ceasing operation. Licensee stated that facility is no longer interested in operating effective February 01, 2024. Original facility license was surrendered to LPA during the visit.

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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