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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201066
Report Date: 08/18/2026
Date Signed: 08/18/2026 02:46:37 PM

Document Has Been Signed on 08/18/2026 02:46 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:GRACE HOME CARE - LLOYDFACILITY NUMBER:
019201066
ADMINISTRATOR/
DIRECTOR:		ROSARIO, GRACE DELFACILITY TYPE:
740
ADDRESS:281 LLOYD STREETTELEPHONE:
(510) 543-8013
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 6DATE:
08/18/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Janette Plata, House Manager TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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POn 8/18/2026 at 8:30 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Felomina Bendana, and explained the purpose of the visit. LPA spoke by phone with Administrator (ADM) Grace Del Rosario and explained the purpose of the visit. ADM certification is active today. ADM was not available during the inspection. LPA received permission from ADM for House Manager Janette Plata to sign the report.

LPA toured the facility, including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. LPA observed smoke and carbon monoxide detectors. Fire extinguishers were full and last serviced on 3/3/2026. One week of nonperishable and 2 days of perishable food supplies were available. LPA observed grab bars and a non-skid mat in the resident's bathroom. The first aid kit is complete. The fire drill was last conducted on June 12, 2026. The emergency disaster plan was last updated and posted on 6/1/26.

(Continue on LIC809C...)

Bennett Fong
Kelly Nguyen
DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2026
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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Document Has Been Signed on 08/18/2026 02:46 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 08/18/2026 at 02:04 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: GRACE HOME CARE - LLOYD
FACILITY NUMBER: 019201066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by having hot water temperature at 131.5 degrees F at the hallway bathroom sink and shared residents' bathroom. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2026
Plan of Correction
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The licensee agrees to immediately adjust and maintain the hot water temperature at the hallway bathroom sink and shared residents’ bathroom within the required regulatory temperature range. The Administrator will conduct and document daily checks of the hot water temperature for 7 consecutive days and weekly thereafter for 30 days to ensure continued compliance. The Administrator will provide staff with in-service training regarding the required hot water temperature and submit documentation of correction and training to CCLD by the POC due date 8/25/26
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by having unlocked chemicals in the shared resident bathroom, RM 3, and the backyard. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2026
Plan of Correction
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The licensee agrees to immediately secure all chemicals and cleaning products in locked storage areas inaccessible to residents. The Administrator will conduct a facility-wide inspection to ensure all chemicals are properly stored and locked. Staff will be reminded of the facility’s chemical storage procedures, and the Administrator will conduct and document weekly checks for 30 days to ensure continued compliance. Documentation of correction and staff training will be submitted to CCLD by the POC due date 8/25/26
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:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2026 02:46 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 08/18/2026 at 02:04 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: GRACE HOME CARE - LLOYD
FACILITY NUMBER: 019201066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked medications in residents' RMs 1, 2, 3, and 4. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2026
Plan of Correction
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The licensee agrees to immediately secure all medication in locked storage areas inaccessible to residents. The Administrator will conduct a facility-wide inspection to ensure all medication are properly stored and locked. Administrator will conduct and document weekly checks for 30 days to ensure continued compliance. Documentation of correction and staff training will be submitted to CCLD by the POC due date 8/25/26
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2026 02:46 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 08/18/2026 at 02:04 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: GRACE HOME CARE - LLOYD
FACILITY NUMBER: 019201066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by having multiple trash bags and containers in the backyard and along the side of the facility. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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The licensee agrees to immediately remove all trash bags and containers from the backyard and along the side of the facility and properly dispose of the waste. The Administrator will conduct a facility-wide inspection to ensure the premises are maintained in a clean, safe, and sanitary condition. Staff will be reminded of proper trash disposal procedures, and the Administrator will conduct and document weekly inspections for 30 days to ensure continued compliance. Documentation of correction will be submitted to CCLD.
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in by having the garage is being used as a sleeping area, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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The licensee agrees to immediately discontinue the use of the garage as a sleeping area and ensure that all residents are provided with appropriate, approved sleeping accommodations. The Administrator will inspect the facility to ensure that no unapproved areas are being used for resident sleeping or living purposes. Staff will be informed of the requirement to use only designated and approved resident areas. The Administrator will monitor compliance and document the corrective action. Documentation of the correction will be submitted to CCLD by the POC due date.
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:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 08/18/2026 02:46 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 08/18/2026 at 02:04 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: GRACE HOME CARE - LLOYD
FACILITY NUMBER: 019201066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having no S3 TB or Health Screen on file on today's date, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2026
Plan of Correction
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The licensee agrees to immediately obtain and maintain the required TB clearance and health screening documentation for S3 in the personnel file. The Administrator will review all staff personnel files to ensure required TB and health screening documentation is complete and current. Staff will be reminded of the facility’s requirements for maintaining these records. The Administrator will monitor personnel files for compliance and submit documentation of correction to CCLD by the POC due date.

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:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2026 02:46 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 08/18/2026 at 02:04 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: GRACE HOME CARE - LLOYD
FACILITY NUMBER: 019201066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by S1 and S2, not associated with the facility. LPA checked Gradian on 8/18/26 at 9:25 AM. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2026
Plan of Correction
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The licensee agrees to immediately ensure that all staff members are properly associated with the facility in Guardian prior to providing services to residents. The Administrator will review the facility’s current staff roster and verify that each staff member is appropriately associated with the facility in Guardian. The Administrator will also review the association status of S1 and S2 and take corrective action as needed. Staff will be reminded of the requirement to maintain current and accurate personnel association records. Documentation of correction will be submitted to CCLD by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2026


LIC809 (FAS) - (06/04)
Page: 7 of 8
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: GRACE HOME CARE - LLOYD
FACILITY NUMBER: 019201066
VISIT DATE: 08/18/2026
NARRATIVE
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LPA reviewed 6 residents' and 4 staff files starting at 9:35 AM. LPA reviewed a sample of residents' medications during inspection.

Deficiencies Observed:

S1 and S2, not associated with the facility. LPA checked Guardian on 8/18/26 at 9:25 AM.

S3 no TB or Health Screen on file on today's date.

LPA observed multiple trash bags and containers in the backyard and along the side of the facility.

LPA measured hot water temperature at 131.5 degrees F at the hallway bathroom sink and shared residents' bathroom.

LPA observed unlocked medications in residents' RMs 1, 2, 3, and 4.

LPA observed unlocked chemicals in the shared resident bathroom, RM 3, and the backyard.

LPA observed the garage is being used as a sleeping area.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

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

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026
LIC809 (FAS) - (06/04)
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