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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700022
Report Date: 01/18/2023
Date Signed: 01/18/2023 12:04:32 PM


Document Has Been Signed on 01/18/2023 12:04 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
CHICO - RESIDENTIAL, 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:
01/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Mary Bot, Administrator TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with administrator Mary Bot during today's inspection. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 4 resident rooms, 1 staff room, 1 bathroom, kitchen, common living spaces, backyard and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator stated there has been no positive COVID cases at the facility, but have an isolation room and additional PPE will be purchased. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete.

Administrator to send CCL a copy of liability insurance, LIC308, and administrator certificate.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
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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