075601395-3-21-2024-15-AS-LAWN-D3KSDD-20240321134700

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601395
Report Date: 03/21/2024
Date Signed: 03/21/2024 01:47:21 PM

Document Has Been Signed on 03/21/2024 01:47 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	GRACE HOMES 2, LLC		FACILITY NUMBER:	075601395
ADMINISTRATOR:	HERBERT, HELEN GRACE S.		FACILITY TYPE:	740
ADDRESS:	423 MCLAUGHLIN STREET		TELEPHONE:	(510) 233-5377
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94805
CAPACITY:	6	CENSUS: 5	DATE:	03/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Helen Herbert, Licensee/Administrator		TIME COMPLETED:	02:00 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 03/21/2024 at 10:30 AM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Carolina Darcen and explained the purpose of the visit. Carolina phoned Licensee/Administrator, Helen Herbert, to inform. Administrator, Helen, arrived shortly after. The facility’s fire clearance was approved for capacity six (6) residents. In which three (3) may be Bedridden. Hospice waiver approved for two (2). Administrator Certificate #6003256740 Expired 06/12/2023. LPA toured facility with Helen including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 4 bedrooms are occupied by the residents and 2 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 69 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 120.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. LIC809-C....Continued

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

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 10

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 HOMES 2, LLC	FACILITY NUMBER: 075601395
	VISIT DATE: 03/21/2024

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
26
27
28
29
30
31
32

LIC809 Continued...

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 12/27/2023. Emergency Disaster Plan was last posted on 02/16/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 02/16/2024.

LPA reviewed 5 residents records. LPA reviewed 4 staff records and 3 of 4 have current first aid training and associated to the facility.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/28/2024:

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

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC809 (FAS) - (06/04)

Page: 10 of 10