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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700022
Report Date: 09/14/2021
Date Signed: 09/14/2021 12:16:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GRACE GARDEN HOME CAREFACILITY NUMBER:
312700022
ADMINISTRATOR:BOT, MARYFACILITY TYPE:
740
ADDRESS:6410 WISP COURTTELEPHONE:
(916) 781-9177
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: 6DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Shevon Witter,CaregvierTIME COMPLETED:
12:30 PM
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On September 14 2021, at 11am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a required 1 year inspection. LPA met with Shevon Witter, caregiver. and explained purpose of inspection. The administrator was unavailable at this time. Prior to initiating the inspection LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: mask. Additionally, LPA was screened by the front desk personnel upon arrival.

LPA completed the inspection tool questionnaire with Shevon no issues or advisories to report.

LPA observed the following:
This is a 6 bedroom 3 bathroom home. Administrator certificate is valid and expires 1/16/2022. First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged. Smoke alarms and Carbon Monoxide detector are working Hot water temperature measured 105 degrees F.
Common areas were clean and in good repair. Bedrooms had required furniture and lighting. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Medication was properly stored and locked away. There are no bodies of water on the premises.

As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6.

Exit interview conducted and a copy of this report given to Shevon Witter
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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