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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601395
Report Date: 04/24/2023
Date Signed: 04/24/2023 05:00:58 PM


Document Has Been Signed on 04/24/2023 05:00 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 HOMES 2, LLCFACILITY NUMBER:
075601395
ADMINISTRATOR:HERBERT, HELEN GRACE S.FACILITY TYPE:
740
ADDRESS:423 MCLAUGHLIN STREETTELEPHONE:
(510) 233-5377
CITY:RICHMONDSTATE: CAZIP CODE:
94805
CAPACITY:6CENSUS: 4DATE:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Helen Herbert, AdministratorTIME COMPLETED:
04:05 PM
NARRATIVE
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On 04/24/2023 at 11:15 AM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced annual required inspection. LPA met with Helen Herbert, Administrator (ADM), and explained the purpose of the visit. LPA toured the facility with ADM who currently holds a certificate (#6003256740) that expires on 06/12/23. The facility’s fire clearance was approved for six (6) ambulatory clients; three (3) may be non-ambulatory and three (3) may be bedridden.

Upon arrival LPA observed two (2) staff attending to residents and one (1) resident dining. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of five (5) total bedrooms which four (4) are occupied by the residents and one (1) by staff. All outdoor and indoor passageways are free of obstruction. There were no bodies of water. A comfortable temperature was maintained at 70 degrees Fahrenheit (F). LPA observed lighting in all rooms to be adequate for the comfort and safety of the residents. Hot water temperature in the shared residents bathroom was measured at 115 degrees (F). All toilets, hand washing, and bathing areas were safe, sanitary and in operating condition. Hand washing poster, paper towels, and soap observed at all hand washing stations. Linen and hygiene product were available for residents. PPE, sanitizer, and paper goods are sufficient.

...continued on LIC9099C.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
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 2


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 HOMES 2, LLC
FACILITY NUMBER: 075601395
VISIT DATE: 04/24/2023
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...continued from LIC9099.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was purchased on 12/08/22. Emergency Disaster Plan is updated. First aid kit was observed to be complete. Fire drill was last conducted on 01/16/23.

Four (4) of four (4) Staff records were reviewed, and all staff have criminal record clearance. All four (4) residents records reviewed were current and complete.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided to ADM.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC809 (FAS) - (06/04)
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