019200327-9-4-2025-15-AS-ADEO-DL7THC-20250904144431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200327
Report Date: 09/04/2025
Date Signed: 09/04/2025 02:44:41 PM

Document Has Been Signed on 09/04/2025 02:44 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 II		FACILITY NUMBER:	019200327
ADMINISTRATOR/ DIRECTOR:	SUSAN MARTINEZ		FACILITY TYPE:	735
ADDRESS:	2223 BECKHAM WAY		TELEPHONE:	(510) 363-9233
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY: 6		CENSUS: 0	DATE:	09/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:20 PM
MET WITH:	Joseph Crisol/Staff-Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:45 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, September 4, 2025 at 12:20 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA rang the doorbell twice, no answer. LPA called and spoke over the phone with Joseph Crisol, staff/assistant administrator (AADM), and informed that LPA is by the front door of the facility and informed the reason for visit. AADM arrived at around 12:55 pm. LPA toured the facility inside out with AADM. 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 111.7 degrees Fahrenheit. Fire extinguishers checked, observed fully charge with tags showed serviced April 16, 2025. LPA reviewed 2 staff files. LPA observed the following: -at 12:59 pm, rotten wood transition strip between resident's room and back patio. -at 1:03 pm, car muffler, old drawer, rusted metal shelf in the backyard. ....continued on 809C

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 09/04/2025

NARRATIVE

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Licensee is applying for the facility to be vendorized by Regional Center of East Bay (RCEB). LPA informed AADM that the facility''s Description/Plan of Operation to reflect the type of clients/residents will admit upon RCEB's vendorization.

LPA verified, and according to AADM, licensee will have the license capacity decreased from 6 to 4 and will house the residents on the ground level. The second floor and basement to be use by staff and that no residents will be house on these floors. LPA informed that the following shall be submitted by September 18, 2025:
1. LIC200 Application for decrease of capacity.
2. Facility sketch showing the following:

Dimension and use of each room
Exit doors and windows
Utility shut off locations
property sketch showing the following: physical plant lay out; perimeter fence; garage and driveway; utility shut off locations

3. LIC9054 Local Fire Inspection Authority Information
Once received, LPA to submit the sketches and STD850 Fire Safety Inspection Request to Fire Department.
4. Application fee for decrease in capacity.

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 civil penalty.

Deficiency and plan and proof of correction were discussed with AADM.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/04/2025 02:44 PM - It Cannot Be Edited

Created By: Alicia Delmundo On 09/04/2025 at 02:10 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: 09/04/2025

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: rotten wood transition strip between resident's room and back patio; car muffler, old drawer, rusted metal shelf in the backyard.
	POC Due Date: 09/18/2025
	Plan of Correction
1 2 3 4	Licensee and/or administrator to do the following and submit pictures by 9/18/25: 1. Have the transition strip replaced. 2. Have the yard cleaned.

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.

	Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:

	Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC809 (FAS) - (06/04)

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