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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201066
Report Date: 07/22/2021
Date Signed: 07/22/2021 02:51:24 PM

Document Has Been Signed on 07/22/2021 02:51 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GRACE HOME CARE - LLOYDFACILITY NUMBER:
019201066
ADMINISTRATOR:ROSARIO, GRACE DELFACILITY TYPE:
740
ADDRESS:281 LLOYD STREETTELEPHONE:
(510) 543-8013
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 5DATE:
07/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Grace Del Rosario, Administrator/ApplicantTIME COMPLETED:
01:00 PM
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On 7/22/2021 at 9:10AM, Licensing Program Analysts (LPAs) G. Luk and C. Fowler conducted an unannounced Pre-licensing Inspection. LPAs met with Administrator/Applicant, Grace Del Rosario.

LPAs inspected the facility inside and out including but not limited to bedrooms, bathrooms, dining room, kitchen, living room, garage, and outdoor area. Hot water temperature was measured at 105 degrees F. No bodies of water observed. Disaster plan was completed on 1/5/2021. Home is clean and well ventilated with appropriate lighting. LPAs observed liability insurance.

Fire extinguisher was last serviced on 3/1/2021. Smoke and carbon monoxide detectors were observed. First aid kit was complete. Facility has a 7-day non-perishable and 2-day perishable food supply.

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. S1 and S3 were not associated to the current facility. Administrator provided LIC9182 and copy of ID to LPAs during inspection.

2. LPAs observed unlocked medication on kitchen counter and medication cabinet was unlocked. Staff locked up medications during inspection.



3. LPAs observed unlocked scissors and gardening tools. Staff locked up scissors and gardening tools during inspection.

4. S3 did not have first aid training on file during record review.
(Continue on LIC809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GRACE HOME CARE - LLOYD
FACILITY NUMBER: 019201066
VISIT DATE: 07/22/2021
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5. S3 does not have health screening and TB test on file during record review.

Licensee/applicant will submit proof of corrections to CCL on/before 8/6/2021.

LPAs conducted Component III with Licensee during inspection. LPAs presented Component III Power Point and discussed the regulations embodied in the presentation.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC809 (FAS) - (06/04)
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