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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200669
Report Date: 07/19/2024
Date Signed: 07/19/2024 01:16:57 PM

Document Has Been Signed on 07/19/2024 01:16 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GOD'S GRACE CARING HOME IIIFACILITY NUMBER:
019200669
ADMINISTRATOR/
DIRECTOR:		CRISOL, JOSEPHFACILITY TYPE:
735
ADDRESS:18540 MADISON AVETELEPHONE:
(510) 921-2234
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 6CENSUS: 5DATE:
07/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Wilma Carvaja, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 7/19/2024 At 11:40 AM, Licensing Program Analysts (LPAs) L.Hall and Ardalan Gharachorloo conducted an unannounced Case Management visit regarding an request for change of administrator that was submitted to CCLD on 7/9/2024. LPA met with Wilma Carvaja, Director Support Professional, Ryan Carvajal, arrived at 11:55am and explained the purpose of the visit.

LPAs conducted a case management visit at another facility where it shows the same Administrator for this facility also LPAs arrived to confirm administrator certification. This facility does not have a certified administrator at this time. LPAs observed during visit and record review that S2, S3, S4, were not associated to the facility.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12- period may result in civil penalties month

Exit interview conducted. A copy of the appeal rights and this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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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Document Has Been Signed on 07/19/2024 01:16 PM - It Cannot Be Edited


Created By: Ardalan Gharachorloo On 07/19/2024 at 12:41 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 III
FACILITY NUMBER: 019200669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/06/2024
Section Cited
CCR
85064(b)

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85064 Adminstrator Qualifications and Duties
(b) All adult residential facilities shall have a certified administrator.
This requirement was not met as evidence by:
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Licensee agreed to implement a plan to hire or certify administrator and submit plan to CCLD by POC date.
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Based on interview and record review the licensee did not comply with the section cited above in having a qualified administrator. which poses a potential health and safety risk to persons in care.
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/19/2024 01:16 PM - It Cannot Be Edited


Created By: Ardalan Gharachorloo On 07/19/2024 at 12:47 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 III
FACILITY NUMBER: 019200669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2024
Section Cited
CCR
80019(e)(3)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) This requirement was not met as evidence by:
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Licensee submitted identifications and will submit LIC9182 to CCLD by POC date.
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Based on observation and record review, the licensee did not comply with the section cited above in having S2, S3 and S4 associated to the facility which poses a potential health and safety risk to persons in care.
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
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