019200669-6-20-2024-15-AS-CFOR-D6ESXJ-20240620141602

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200669
Report Date: 06/20/2024
Date Signed: 06/20/2024 02:16:15 PM

Document Has Been Signed on 06/20/2024 02:16 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 III		FACILITY NUMBER:	019200669
ADMINISTRATOR:	CRISOL, JOSEPH		FACILITY TYPE:	735
ADDRESS:	18540 MADISON AVE		TELEPHONE:	(510) 921-2234
CITY:	CASTRO VALLEY	STATE: CA	ZIP CODE:	94546
CAPACITY:	6	CENSUS: 5	DATE:	06/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	RYAN CARVAJAL, ADMINISTRATOR		TIME COMPLETED:	03:15 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 06/20/2024 at 10:00AM, Licensing Program Analyst (LPA)Carol Fowler conducted an unannounced annual required inspection. LPA met with Ryan Carvajal, Administrator, and explained the purpose of the visit. LPA toured the facility with Administrator. Administrator, Ryan Carvajal, holds an Administrator Certificate 6052147735 ex 6/27/2023 (waiting for renewed certificate). The facility’s fire clearance was approved for six (6) non-ambulatory clients. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) total bedrooms and three (3) bathrooms two (2) bedrooms and one (1) bathroom is used by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 120 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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 3

Document Has Been Signed on 06/20/2024 02:16 PM - It Cannot Be Edited

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 III	FACILITY NUMBER: 019200669
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a cabinet in the kitchen unlocked which contained chemicals, Windex, Easy Off, Comet, Clorox Spray, 2 Torch Lighters, scissors and knives. which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	Administrator agreed to keep cabinets that contain chemicals and sharps locked at all times. DEFICIENCY CLEARED DURING VISIT.

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	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 III	FACILITY NUMBER: 019200669
	VISIT DATE: 06/20/2024

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

Continued from LIC809.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/28/2023. Emergency Disaster Plan was last posted on 10/20/2023. First aid kit was observed to be complete. Fire drill was last conducted on 2/10/2024, facility next disaster drill will conducted on 06/21/2024.

Four (3) staff records reviewed and complete. Four (4) clients records reviewed, current, and complete. LPA also reviewed P & I and medication.

Deficiency observed by LPA during visit:

At 11:41am LPA observed an unlocked cabinet under the sink located in the kitchen which contained chemicals, Windex, Easy Off, Comet, Clorox Spray, 2 Torch Lighters, scissors and knives.

The following forms to be updated and submitted to CCLD by 7/01/2024:

· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC610D emergency disaster plan
· Client roster
· LIC308 Designation of facility responsibility

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809 & 809C, LIC-809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3