075601395-12-15-2020-15-AS-KHOS-BWCNAL-20201216091744

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601395
Report Date: 12/15/2020
Date Signed: 12/15/2020 11:41:27 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20201130151017

FACILITY NAME:	GRACE HOMES 2, LLC		FACILITY NUMBER:	075601395
ADMINISTRATOR:	HERBERT, HELEN GRACE S.		FACILITY TYPE:	740
ADDRESS:	423 MCLAUGHLIN STREET		TELEPHONE:	(510) 233-5377
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94805
CAPACITY:	6	CENSUS: 6	DATE:	12/15/2020
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Helen Grace Herbert/Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are inappropriately locking residents in the facility.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On this day, December 15, 2020, Licensing Program Analyst (LPA) Delmundo conducted a tele-visit with Helen Grace Herbert, administrator, to deliver the finding on the allegation. LPA explained the reason for the tele-visit and that due to the Shelter in Place Order and management directive to telework, LPA was unable to deliver the finding in person.

It was alleged that staff are inappropriately locking residents in the facility. It was reported that a slide lock was installed on the front door to keep residents from wandering.

....continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Isaac Taggart	TELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 15-AS-20201130151017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOMES 2, LLC	FACILITY NUMBER: 075601395
	VISIT DATE: 12/15/2020

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

During investigation, LPA conducted inspection and interviews. Staff (S1 and S2) indicated that the slide lock which was installed to keep resident from wandering was removed sometime last month. During inspection on December 8, 2020, LPA observed nail/screw marks at the lower portion of the front door. Although the front door was observed with working auditory signal, a slide lock was observed on the top portion of the same door.

Based on the information obtained, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Any repeat violations within 12-month period may result in civil penalties.

Deficiency, and plan and proof of corrections were discussed with Ms. Herbert.

Exit interview conducted. Appeal Rights and copy of this report provided via e-mail to Ms. Herbert.

SUPERVISOR'S NAME: Isaac Taggart	TELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20201130151017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOMES 2, LLC	FACILITY NUMBER: 075601395
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/22/2020 Section Cited HSC 1569.269(a)(5)	1 2 3 4 5 6 7	1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have.... the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.	1 2 3 4 5 6 7	Corrected. Pictures showing slide lock was removed received on 12/09/2020.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: -Based on inspection, observation and interviews, the licensee did not comply with the above Regulation by having a slide lock on the front door which poses potential personal rights and safety risks to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Isaac Taggart	TELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3