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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201371
Report Date: 02/11/2025
Date Signed: 02/11/2025 10:31:20 AM

Document Has Been Signed on 02/11/2025 10:31 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:
02/11/2025
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Licensee, Filmon Yemane Gebrekidan/
Administrator, Filmon Berhe Woldemariam		TIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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On 02/11/2025 at 10:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived announced to amend report previously issued on 02/06/2025. LPA met with Licensee, Filmon Yemane Gebrekidan/Administrator, Filmon Berhe Woldemariam


LPA T. Syess-Gibson amended report (LIC809) previously issued on 02/06/2025. LPA printed the amended reports and provided a copy to Licensee, Filmon Yemane Gebrekidan/Administrator, Filmon Berhe Woldemariam



Exit interview conducted. A copy of the reports was provided.
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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