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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601446
Report Date: 06/17/2021
Date Signed: 06/17/2021 04:30:08 PM

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 MANORFACILITY NUMBER:
075601446
ADMINISTRATOR:ANNIE DEL ROSARIOFACILITY TYPE:
740
ADDRESS:3744 PINTAIL DRIVETELEPHONE:
(925) 706-9922
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 6DATE:
06/17/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Anatol Del Rosario, Administrator and Amalia Burton, LicenseeTIME COMPLETED:
04:30 PM
NARRATIVE
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On 6/17/2021 at 1:35pm, Licensing Program Analyst (LPA) L. Hall conducted an case management visit while conducting a pre-licensing inspection. LPA met with Anatol Del Rosario, Administrator and Amalia Burton, Licensee.

Upon entry LPA observed a screening station at the front door. There were not any COVID-19 signs posted. LPA's was not screened and temperature was not checked. LPA observed there were not any hand washing signs at any of the hand washing stations or any COVID-19 signs posted around the facility. LPA toured the facility with the Licensee and Administrator.

LPA observed the following deficiencies:

- On 6/17/2021 at 09:50am, LPA observed 4 staff not wearing masks.
- On 6/17/2021 at 09;50am, LPA observed there were not any COVID-19 signs posted at facility.
- On 6/17/2021 at 10:15am, LPA observed two (2) oxygen tanks sitting on the floor in bedroom #2.
- On 6/17/2021 at 10:40am, LPA observed staff room located off the rear of the kitchen with door open and medication accessible.
- On 6/17/2021 at 10:50am, LPA observed storage shed in backyard unlocked.
- On 6/17/2021 at 10:50am, LPA observed garden tools (shovel, dirt digger), a wheel barrow, 2 ladders, wood debris, metal bars, and an air gun located in backyard.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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 5
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 MANOR
FACILITY NUMBER: 075601446
VISIT DATE: 06/17/2021
NARRATIVE
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Continued from LIC809.

- On 6/17/2021 at 11:55am, LPA observed facility was not conducting fire drills and did not have a log.
-On 6/17/2021 at 11:55am, LPA observed facility did not have a mitigation plan.

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 06/25/2021:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Updated facility sketch.
Mitigation Plan.

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

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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 MANOR
FACILITY NUMBER: 075601446
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2021
Section Cited

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87465 (h)...requirements shall apply to medications which are centrally stored (2)...medicines shall be kept in a safe and locked place that is not accessible.... This requirement was not met as evidence by:
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Based on observation the licensee did not comply with the section cited above. LPA observed sliding door to staff room open and medicines accessible, which poses an immediate health and safety risk to persons in care.
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Type A
06/18/2021
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents...a: (1) Knives, matches, firearms, tools and other items... this requirement was not met as evidence by:
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Based on observation the licensee did not comply with the section cited above. LPA observed a unlocked shed in the backyard with garden tools. And garden tools and other debris sitting in backyard.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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 MANOR
FACILITY NUMBER: 075601446
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2021
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... This requirement was not met as evidence by:
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Based on record review the icensee did not comply with the section cited above. LPA observed the facility did not have a mitigation plan, which poses a potential health and safety risk to persons in care.
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Type B
06/24/2021
Section Cited

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87618 Oxygen Administration (3) Ensuring that the use of oxygen equipment meets the following requirements: E) Oxygen tanks that are not portable shall be secured in a stand... This requirement was not met as evidence by:
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Based on observation the licensee did not comply with the section cited above. LPA observed 2 oxygen tanks sitting on the floor in bedroom #2.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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 MANOR
FACILITY NUMBER: 075601446
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2021
Section Cited

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87705 (k)The following initial and continuing requirements must be me...3) Fire and earthquake drills shall be conducted at least once every three months....This requirement was not met as evidence by:
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Based on record review the licensee did not comply with the section cited above , LPA observed there was not a fire drill log and drills were not being conducted, which poses a potential health and safety risks to persons in care.
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Type B
06/17/2021
Section Cited

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87411 (f) All personnel, including the licensee and administrator, shall be in good health... capable of performing assigned tasks. This requirement was not met as evidence by:
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Based on observation the licensee did not comply with the section cited above , LPAsobserved that 4 staff were not wearing mask at the facility which poses a potential health and safety risks 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5