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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200041
Report Date: 07/19/2024
Date Signed: 07/19/2024 11:20:42 AM

Document Has Been Signed on 07/19/2024 11:20 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 IIIFACILITY NUMBER:
019200041
ADMINISTRATOR/
DIRECTOR:		JOSEPH G. CRISOLFACILITY TYPE:
735
ADDRESS:16950 MELODY WAYTELEPHONE:
(510) 200-7747
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 6CENSUS: 5DATE:
07/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Nida Acosta, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On 7/19/2024 at 10:00am, Licensing Program Analysts (LPAs) L. Hall and Ardalan Gharachorloo conducted an unannounced Case Management visit regarding an request for change of Administrator that was submitted to CCLD on 7/9/2024. LPA met with Nida Acosta, Direct Support Professional. Administrator, Ryan Carvajal, arrived at 10:50am and explained the purpose of the visit.

LPA L. Hall while received the request to change the Administrator; however, there were not any documents attached. LPAs conducted the visit to confirm facility has an certified administrator. The facility does not have a certified administrator at this time.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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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Document Has Been Signed on 07/19/2024 11:20 AM - It Cannot Be Edited


Created By: Laura Hall On 07/19/2024 at 11:09 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 III
FACILITY NUMBER: 019200041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2024
Section Cited
CCR
85064(b)

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85064 Adminstrator Qualifications and Duties
(b) All adult residential facilities shall have a certified administrator.
This requirement was not met as evidence by:
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Licensee agreed to implement a plan to hire or recertify administrator and submit plan to CCLD by POC date.
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Based on interview and record review the Licensee did not comply with the section cited above in having a qualified administrator, which poses a potential health and safety risk to persons in care.
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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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
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