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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201371
Report Date: 01/28/2025
Date Signed: 01/28/2025 01:27:51 PM

Document Has Been Signed on 01/28/2025 01:27 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:GRACE SENIORS CAREFACILITY NUMBER:
079201371
ADMINISTRATOR/
DIRECTOR:		WOLDEMARIAM, FILMON BERHEFACILITY TYPE:
740
ADDRESS:1368 SANDSTONE DR.TELEPHONE:
(614) 641-1813
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 0DATE:
01/28/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Licensee, Filmon Yemane Gebrekidan/Administrator, Filmon Berhe WoldemariamTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On 01/28/2025 at 10:15AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted a Pre-licensing Inspection. LPA met with Licensee, Filmon Yemane Gebrekidan/Administrator, Filmon Berhe Woldemariam

LPA toured facility including but not limited to resident's bedrooms, bathrooms, living room, dining area, kitchen, garage, and outdoor area. LPA observed lighting in all rooms.

LPA observed facility had some non-perishable food supply. Licensee will purchase additional food supplies once facility is licensed. Carbon monoxide and smoke detectors was observed in operating condition. First aid kit was complete. Emergency disaster plan was complete. Fire Extinguisher last serviced on 03/08/2024.

LPA will conduct the Comp III presentation on next visit.

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

1. LPA observed Hot water was measured at 140.1 degrees F in the shared bathroom sink.


2. LPA observed the common bathrooms does not have paper towel holders.

3. LPA observed common bathrooms does not have night lights available.

4. LPA observed bedroom #1 is missing a bed, chair and chest of drawers.

Continue on LIC809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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 9
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: GRACE SENIORS CARE
FACILITY NUMBER: 079201371
VISIT DATE: 01/28/2025
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Continued from LIC809

5. LPA observed all six (6) beds in residents rooms does not have blankets, bedspreads, top bed sheets and mattress pads.

6. LPA observed facility does not have signal system.

7. LPA observed facility does not have Resident Rights/Information -20"x 26" PUB 475 poster

8. LPA observed Outdoor activity areas that are easily accessible to residents, does not have adequate shady area for residents. Licensee/Administrator has ordered table with umbrella.

9. LPA observed back gate has a mechanical lock and facility does not have a fire clearance with locked perimeter. LPA requested licensee to either obtain property fire clearance or remove the mechanical lock on back gate. Licensee/Administrator agreed to remove the lock.

Licensee/Applicant will make the corrections before 2/6/2025.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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