015601191-4-10-2023-15-AS-PWAN-CQRPWP-20230410114103

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601191
Report Date: 04/10/2023
Date Signed: 04/10/2023 11:41:21 AM

Document Has Been Signed on 04/10/2023 11:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	GRACE HOME CARE		FACILITY NUMBER:	015601191
ADMINISTRATOR:	DEL ROSARIO, GRACE		FACILITY TYPE:	740
ADDRESS:	17121 VIA ALAMITOS		TELEPHONE:	(510) 317-7548
CITY:	SAN LORENZO	STATE: CA	ZIP CODE:	94580
CAPACITY:	6	CENSUS: 5	DATE:	04/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Marcelina Olisa, Caregiver		TIME COMPLETED:	12:00 PM

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	On 4/10/2023 at 9:00 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA was greeted by Marcelina Olisa and explained the purpose of the visit. LPA spoke with Administrator, Grace Del Rosario, on the phone. Administrator was unable to join the visit and allowed Marcelina to sign the documents. The facility’s fire clearance was approved for 6 Non-ambulatory. LPA toured facility with Marcelina including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats.There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 3/28/2023. Emergency Disaster Plan was last updated on 11/21/2022. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 11/21/2022. Report continues on 809 C.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRACE HOME CARE	FACILITY NUMBER: 015601191
	VISIT DATE: 04/10/2023

NARRATIVE

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At 9:50 AM, LPA reviewed 5 residents records. At 10:30 AM, LPA reviewed 5 staff records and 5 of 5 have current first aid training and associated to the facility. At 11:15 AM, LPA reviewed a sample of resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 4/25/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC809 (FAS) - (06/04)

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