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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200327
Report Date: 08/30/2024
Date Signed: 08/30/2024 02:07:01 PM

Document Has Been Signed on 08/30/2024 02:07 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/
DIRECTOR:		SUSAN MARTINEZFACILITY TYPE:
735
ADDRESS:2223 BECKHAM WAYTELEPHONE:
(510) 363-9233
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 0DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Angeles Jonson/StaffTIME VISIT/
INSPECTION COMPLETED:
02:10 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 this day, August 30, 2024, at 11:30 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA rang the doorbell several times; no answer. LPA called and spoke over the phone with Susan Martinez, licensee-administrator, and informed the reason for visit. Licensee-administrator stated she'll call the staff. LPA was granted entry after about 15 minutes by Angeles Jonson.

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

LPA toured the facility inside out with Angeles Jonson. The facility is a three level (street level, second floor and basement) building. LPA inspected the living and dining rooms, kitchen, bedrooms, bathrooms, front, side and backyards. Currently, the facility does not have residents.

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 116 degrees Fahrenheit. Fire extinguishers checked, observed fully charge with tags showed serviced April 29, 2024.

LPA reviewed 2 staff files.

LPA observed the following:
-at 11:50 am, sliding and screen doors in the kitchen leading to the porch at the back in the street level floor are very tight when being opened.
-at 12:09 pm, hole on the wall on the second floor

.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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 4
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: 08/30/2024
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
26
27
28
29
30
31
32
Page 2

Administrator to submit the following updated/current documents by September 13, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)

Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in additional civil penalties.

Deficiency and plan and proof of correction were discussed with licensee-administrator over the phone who authorized to have the staff sign and receive this report.

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

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/30/2024 02:07 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/30/2024 at 01:44 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: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the following: sliding door and screen door very tight when being opened; hole in the wall.
POC Due Date: 09/13/2024
Plan of Correction
1
2
3
4
Licensee to have the doors fixed and wall repaired, and submit pictures by 9/13/24.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4