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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201371
Report Date: 02/06/2025
Date Signed: 02/11/2025 10:29:17 AM

Document Has Been Signed on 02/11/2025 10:29 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
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:
02/06/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Licensee, Filmon Yemane Gebrekidan/
Administrator, Filmon Berhe Woldemariam		TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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***THIS IS AN AMENDMENT OF PRE-LICENSING REPORT DATED 02/06/2025.***

On 02/06/2025 at 10:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrive announced to conduct a Pre-licensing Inspection to verify corrections were made from visit on 01/28/2025. LPA met with Licensee, Filmon Yemane Gebrekidan/Administrator, Filmon Berhe Woldemariam. The facility’s fire clearance was approved for five (5) non ambulatory and one (1) bedridden resident.


LPA toured facility but not limited to resident's bedrooms, bathrooms, living room, kitchen, and outdoor area.
LPA observed all six (6) beds in residents’ rooms have blankets, bedspreads, top bed sheets, mattress pads and bedroom #1 to be complete with bed, chair and chest of drawers.

LPA also observed signal system in kitchen and call buttons in residents’ rooms. LPA measured hot water at 109.2 degrees F. LPA observed paper towel with paper towel holders and night lights in residents shared bathroom. LPA observed facility does have resident rights/information -20"x 26" PUB 475 poster posted in entry of facility. LPA observed delivery date for outdoor table with umbrella is scheduled to arrive today on 02/06/2025. LPA observed mechanical lock in the backyard was removed and replaced.

LPA conducted COMP III with Licensee and Administrator during visit.


Continue LIC809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GRACE SENIORS CARE
FACILITY NUMBER: 079201371
VISIT DATE: 02/06/2025
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Continued from LIC809


The licensee/administrator was reminded of the statute that requires CCL to be notified within 5 business days of admitting their first resident. This notification may be done by phone, by mail, or by fax.


No Issues were noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.


Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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