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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200327
Report Date: 09/28/2022
Date Signed: 09/28/2022 03:05:41 PM

Document Has Been Signed on 09/28/2022 03:05 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GOD'S GRACE CARING HOME IIFACILITY NUMBER:
019200327
ADMINISTRATOR:SUSAN MARTINEZFACILITY TYPE:
735
ADDRESS:2223 BECKHAM WAYTELEPHONE:
(510) 363-9233
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 5DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Staff Celine Medina and
Angeles 'Gil' Angeles		TIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with care staff, Celine Medina and Angeles 'Gil' Jonson, and informed the purpose of visit. LPA called and spoke with Joseph Crisol, administrator. Administrator stated he can not come to the facility to meet LPA and authorized Celine Mediina to sign and receive this report.

Facility has an approved LIC808 Mitigation Plan on file. Administrator has not submitted the new Infection Control Plan and started he'll submit before the end of the day today.

LPA toured the facility inside out with Medina. LPA inspected the living and dining rooms, kitchen, hallways, bathrooms. bedrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station near the front entrance with hand sanitizer, no touch temperature probe, sanitizing wipes and Visitor's Log. Visitor's temperature and symptom checks are done at the entrance. Residents and staff are screened for COVID-19 symptoms, and temperature checked and recorded daily. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs checked and observed adequate for 30 days, and antigen test kits are readily available. Trash bins were observed with foot pedal operated lids. Bathroom lavatories were observed with liquid soap and paper towels. Staff were fit tested for N95 respirator August 19, 2021. LPA verified, and administrator stated re-certification is scheduled for October 3, 2022.
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Fire extinguisher checked and observed fully charge with tag showed serviced April 21, 2022. Hot water temperature in one of the common bathrooms was tested and measured at 105 degrees Fahrenheit.

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SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARING HOME II
FACILITY NUMBER: 019200327
VISIT DATE: 09/28/2022
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The following updated/current documents to be submitted by October 5, 2022:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Updated N95 Fit Testing records

No deficiency cited on this day.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
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