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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201066
Report Date: 09/15/2023
Date Signed: 09/15/2023 11:39:06 AM

Document Has Been Signed on 09/15/2023 11:39 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
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:
09/15/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Amalia Saptang, CaregiverTIME COMPLETED:
11:50 AM
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On 9/15/2023 at 10:20AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a POC (proof of correction) inspection. LPA met with caregiver, Amalia Saptang informed her the reason for the visit.

The following deficiencies were cleared by visit:
- 87411(f); LPA received S2's health screening on 8/28/23.
- 1569.695(c); LPA received emergency drill on 8/28/23. Emergency drill was conducted on 8/11/23.
- 87411(c)(1); LPA received S1's first aid certificate on 8/28/23. S1's first aid expires on 8/13/25.
- 87506(d); LPA observed R2 and R3's files were complete and available for review.
- 1569.69(a)(2); LPA was informed that S2 had resigned a couple weeks ago and no longer works at the facility. Administrator submitted a written statement that all staff will have medication training completed.


No deficiencies are being cited on this date.


Exit interview conducted. A copy of this report and POC letters provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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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