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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200327
Report Date: 09/21/2023
Date Signed: 09/22/2023 11:21:41 AM

Document Has Been Signed on 09/22/2023 11:21 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 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:
09/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Staff, Estrella Bunag
and Celine Medina		TIME COMPLETED:
06:00 PM
NARRATIVE
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On this day, September 21, 2023, at 10:50 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Estrella Bunag, staff, and informed the purpose of visit. LPA also met with other staff, Celine Medina. LPA called and spoke with Joseph Crisol, house manager, who authorized Estrella Bunag to be with LPA during inspection. LPA also called Susan Martinez, licensee-administrator, and left message on her voice mail.

Facility has Infection Control Plan that was submitted, and received by LPA on September 29, 2022.

LPA toured the facility inside out. The facility is a three level (street level, second floor and basement) building. LPA inspected the living and dining rooms, kitchen, residents' rooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Knives where kept was observed locked.

Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in one of the bathrooms was tested, and measured at 117.7 degrees Fahrenheit. Fire extinguisher checked, observed fully charge with tag showed serviced May 5, 2023. Facility conducts disaster drills, and records showed last conducted May 3, 2023.

LPA reviewed 5 staff and 5 residents files, and interviewed 2 staff and 2 residents. Medications checked, and compared with records and doctor's orders. Residents' P&Is were checked and compared with records.

LPA observed the following:
-at 11:17 am, Lysol cleaning agent in the bathroom on the second floor.

.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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: 09/21/2023
NARRATIVE
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-at 12:42 pm, observed 4 of residents' actual P&I cash do not match records.
-at 2:30 pm, resident (R3) LIC602 Physician's Report indicated non-ambulatory. LPA also observed R3 using walker to ambulate.
-at 4:00 pm. resident (R2) has doctor's order for 1 medication which is also listed on September 2023 LIC622 Centrally Stored Medication and Destruction Record but the facility does not have the medication.

Administrator to submit the following updated/current documents by October 5, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 civil penalty is assessed for section 80020(a). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12 month period may result in additional civil penalties.

Deficiencies and plan and proof of corrections were discussed with Joseph Crisol who authorized to have the staff sign and receive this report.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty, LIC9098 Proof of Correction form and copy of this report provided to Celine Medina.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/22/2023 11:21 AM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/21/2023 at 04:41 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 CARING HOME II
FACILITY NUMBER: 019200327

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for Lysol in the common bathroom which poses an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
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Staff locked the item.
Administrator to in-service the staff and submit copy of training topic with attendeed signatures by 9/22/23.
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in for 1 out of 5 resident non-ambulatory when license and fire clearance are ambulatory only which pose an immediate safety risk to person in care.
A $500.00 civil penalty is assessed.
POC Due Date: 09/22/2023
Plan of Correction
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House manager submitted the LIC200 signed by the licensee, updated sketch and LIC9054 while LPA is still at the facility.
Licensee to work with Local Fire Department for inspection and approval of fire clearace.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/22/2023 11:21 AM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/21/2023 at 04:41 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 CARING HOME II
FACILITY NUMBER: 019200327

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above for resident (R2) who has doctor's order for 1 medication but the facility does not have the medication. which poses an immediate health and/ or personal rights risk to person in care.
POC Due Date: 09/22/2023
Plan of Correction
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Administrator to check with the doctor if the medication is no longer needed, and obtain discontinued order, otherwise, obtain the medication and administer accordingly. Proof to be submitted by 9/22/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/22/2023 11:21 AM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/21/2023 at 04:41 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 CARING HOME II
FACILITY NUMBER: 019200327

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above for residents who P&I cash do not match records which pose a potential personal rights risks to persons in care.
POC Due Date: 10/05/2023
Plan of Correction
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Administrator to reconcile records, and submit copies of LIC 405 Record Of Client's/Resident's Safeguarded Cash Resources by 10/05/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


LIC809 (FAS) - (06/04)
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