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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201414
Report Date: 11/07/2024
Date Signed: 11/07/2024 01:52:12 PM

Document Has Been Signed on 11/07/2024 01:52 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:LIGHT OF GRACE IFACILITY NUMBER:
079201414
ADMINISTRATOR/
DIRECTOR:		ABDULLAH-GRAYSON, TARRAFACILITY TYPE:
740
ADDRESS:34 MORNING GLORY CT.TELEPHONE:
(925) 303-5503
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 0DATE:
11/07/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:41 AM
MET WITH:Tarra Abdullah-Grayson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:03 PM
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On 11/07/2024 at 10:41am, Licensing Program Analyst (LPA) T.Syess-Gibson conducted an announced pre-licensing visit and met with applicant Tarra Adbullah-Grayson, Administrator. LPA explained the purpose of the visit with Administrator. The facility has an approved fire safety clearance for total capacity of six (6) residents, five(5) non ambulatory and one (1) bedridden residents.

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage, back yard. The facility has five (5) bedrooms and three (3) bathrooms. One(1) bathroom used by staff only. There is sufficient lighting around the facility.

LPA observed all five (5) residents' rooms equipped with proper beddings each bed had clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases and mattress pads. All rooms have proper lighting. LPA observed Bathrooms showers were equipped with grab bars, non-skid mats and hygiene supplies were observed inside cabinet. LPA observed television in the common area and board games for activities.

Communal dining room is equipped with sufficient tables and chairs for the residents. All toxins were locked inside the laundry room . Sharps and disinfectants were locked in cabinet in kitchen. Passageways and hallways were free of obstruction. Fire extinguishers were last purchased on 05/23/2024. Smoke detectors and Carbon Monoxide detectors were operational. Medication cabinet was locked, and first aid kit was complete.

Continue LIC809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LIGHT OF GRACE I
FACILITY NUMBER: 079201414
VISIT DATE: 11/07/2024
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Continue from LIC809

All exit doors in the facility are equipped with auditory signals. Hot water temperature is measured at 116.1 degrees F. Emergency Disaster plans are complete and easily accessible to staff. Comfortable temperature was observed at 72 degrees F

No issues noted during this pre-licensing inspection.

Component III was conducted with Tarra Abdullah-Grayson on pre-licensing visit dated 11/07/2024. The applicant was reminded of the statute that requires CCL to be notified within 5 business days of admitting their first resident. This notification may be done by phone, by mail, or by fax.


LPA observed the facility is ready to be licensed. This report will be submitted to the central application unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.


Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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