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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200669
Report Date: 06/06/2022
Date Signed: 06/06/2022 03:32:11 PM

Document Has Been Signed on 06/06/2022 03:32 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 IIIFACILITY NUMBER:
019200669
ADMINISTRATOR:CRISOL, JOSEPHFACILITY TYPE:
735
ADDRESS:18540 MADISON AVETELEPHONE:
(510) 921-2234
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 6CENSUS: 5DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rayan Jayson V. Carvajal, AdministratorTIME COMPLETED:
03:45 PM
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On 6/6/22 at 2:00 PM, Licensing Program Analysts (LPAs) K. Nguyen and C. Lin arrived unannounced to conduct Infection Control Inspection. LPAs met with Rayan Jayson V. Carvajal Administrator to explain the purpose of the visit.
During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan.
During record review, LPAs reviewed a sample of 2 staff records and observed 2 of 2 have health screening with TB test on file.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 6/13/2022:

LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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