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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201371
Report Date: 02/19/2026
Date Signed: 02/19/2026 02:49:48 PM

Document Has Been Signed on 02/19/2026 02:49 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 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: 2DATE:
02/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Yodit Gebreyohannes, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 2/19/2026 at 12:10pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Yodit Gebreyohannes, Caregiver. Administrator, Filmon Woldemariam, arrived at 1:05pm, and LPA explained the purpose of the visit. Administrator holds a certificate #6070561740 expires 5/9/2026. The facility’s fire clearance was approved for five (5) non-ambulatory and 1 (one) bedridden resident. Facility has a hospice waiver for one (1).

LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) bedrooms and three (3) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced 3/15/2025. Fire drill last conducted on 1/25/2026. Emergency Disaster Plan was last reviewed on 5/1/2025. First aid kit was observed to be complete.

Continued on LIC809.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2026
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 SENIORS CARE
FACILITY NUMBER: 079201371
VISIT DATE: 02/19/2026
NARRATIVE
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Continued from LIC809C.

LPA reviewed both resident and staff records, all were current and complete. LPA also reviewed medications.

LPA requested the following documents to be submitted to CCLD by 2/26/2026.
  • LIC308 Designation of Administrative Responsibility
  • Liability insurance.
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan. (9 pages)
  • Administrator certificate


LPA observed the following deficiencies:
  • At 12:30pm, LPA observed the facility did not have a 7-day supply or non-perishables and 2-day perishable foods.
  • At 12:47pm, LPA observed laundry room turned into staff room.
  • At 12:55pm, LPA observed R1 and R2 having half bed rails with no doctor orders.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/19/2026 02:49 PM - It Cannot Be Edited


Created By: Laura Hall On 02/19/2026 at 02:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRACE SENIORS CARE
FACILITY NUMBER: 079201371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in notifying CCLD and receiving clearance for alteration which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2026
Plan of Correction
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Administrator agreed to submit LIC200 and updated facility sketch to CCLD by POC date.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a 7-day supply of non-perishables and 2-day perishable foods which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2026
Plan of Correction
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Administrator agreed to purchase a variety of foods and submit photos to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 02/19/2026 02:49 PM - It Cannot Be Edited


Created By: Laura Hall On 02/19/2026 at 02:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRACE SENIORS CARE
FACILITY NUMBER: 079201371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having doctor orders for half rails for R1 and R2 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2026
Plan of Correction
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Administrator agreed to obtain doctor orders for half rails for R1 and R2 and submit a copy to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


LIC809 (FAS) - (06/04)
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