<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200041
Report Date: 12/23/2024
Date Signed: 12/23/2024 04:32:57 PM

Document Has Been Signed on 12/23/2024 04:32 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GOD'S GRACE IIIFACILITY NUMBER:
019200041
ADMINISTRATOR/
DIRECTOR:		JOSEPH G. CRISOLFACILITY TYPE:
735
ADDRESS:16950 MELODY WAYTELEPHONE:
(510) 200-7747
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Caregiver Nida AcostaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/23/2024 at 12:00 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Caregiver Nida Acosta.

The LPA inspected the facility inside and outside. All outdoor and indoor passageways were free of obstruction. Outside, there were no bodies of water. Inside, the temperature was in the safe temperature range. The LPA observed adequate lighting in all of the rooms for the comfort and safety of the individuals. The hot water temperature was measured to be in the safe range. The LPA observed more than the minimum of 7 days of nonperishable and 2 days of perishable foods on hand. Sharps and other dangerous items were stored inaccessibly to residents. Smoke and carbon monoxide detectors were in operating condition. Fire extinguishers observed to be fully charged and last serviced on 4/3/2024.

The LPA reviewed the records of 5 consumers and 5 staff members.

1 B-Type citation issued (refer to LIC 809-D for details).

Exit interview conducted and a copy of this report provided.
Harpreet HumpalTELEPHONE: (510) 529-9416
James SampairTELEPHONE: (510) 286-4201
DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/23/2024 04:32 PM - It Cannot Be Edited


Created By: James Sampair On 12/23/2024 at 04:04 PM
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 III
FACILITY NUMBER: 019200041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above because the 2021 version of LIC 610D and LIC 999 yard sketch with assembly point were never completed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2025
Plan of Correction
1
2
3
4
On or before the due date, the Licensee shall complete the 2021 version of the LIC 610D and Yard Sketch of the LIC 999.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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
TELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME:James Sampair
TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2