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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201414
Report Date: 12/11/2024
Date Signed: 12/11/2024 01:58:53 PM

Document Has Been Signed on 12/11/2024 01:58 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: 1DATE:
12/11/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Barbara McMillion, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:18 PM
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On 12/11/2024 at 1:00PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced post licensing inspection. LPA met with Barbara McMillion, Caregiver. Barbara contacted Administrator, Tarra Abdullah-Grayson via telephone and advised purpose of visit. Administrator, Tarra Abdullah-Grayson gave authorization to Barbara McMillion to sign the reports.

LPA toured facility including but not limited to bedrooms, bathrooms, dining area, living room, kitchen, garage, and outdoor area. Fire extinguisher was observed to be full and last purchased on 05/23/2024. Medications were in a locked cabinet in the kitchen. Comfortable room temperature is maintained at 74 degrees F. Hot water temperature in the shared residents’ bathroom was measured at 111.1 degrees Fahrenheit. One week of non-perishable and 2-day perishable food supplies were sufficient.

Carbon monoxide and smoke detectors were observed in operating condition. First-aid kit was complete, and hygiene items for resident general use are sufficient. Extra linens and towels were observed in the hallway closet. Last fire drill was conducted on 11/20/2024. There are no accessible bodies of water observed.

LPA reviewed one (1) out of one (1) resident’s record and three (3) staff records starting at around 1:15PM. All staff are fingerprint cleared and associated to the facility. The resident in care has a physician's report, needs & service plan, and admission agreement on file. LPA also reviewed one (1) resident’s medication and medication logs. All PRN medications have physician's orders. LPA attempted to interview resident however, wasn't successful as the resident has dementia and is non verbal.

Continue on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LIGHT OF GRACE I
FACILITY NUMBER: 079201414
VISIT DATE: 12/11/2024
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Continued from LIC809


No deficiencies cited during visit.

The following forms to be updated and submitted to CCL by 12/18/2024:

· LIC 500- Personnel Report
· LIC 308- Designation of Facility Responsibility
· LIC 610E- Emergency/Disaster Plan (9 pages)
· Evidence of Liability Insurance

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

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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