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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700022
Report Date: 12/11/2024
Date Signed: 12/11/2024 05:28:03 PM

Document Has Been Signed on 12/11/2024 05:28 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GRACE GARDEN HOME CAREFACILITY NUMBER:
312700022
ADMINISTRATOR/
DIRECTOR:
BOT, MARYFACILITY TYPE:
740
ADDRESS:6410 WISP COURTTELEPHONE:
(916) 781-9177
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Melisa, George, and Mary BotTIME VISIT/
INSPECTION COMPLETED:
05:35 PM
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Licensing Program Analyst (LPA) Kerry Hiratsuka arrived unannounced to conduct an annual inspection. LPA met with Co-Administrators George, Mary, and Melisa Bot.

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. The Administrators created an office out of the laundry room. The laundry machines are now next to the caregiver room. 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.

The following shall be updated and submitted to Community Care Licensing by the end of the month:
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility

Multiple topics discussed

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

Exit interview conducted.
Troy OrdonezTELEPHONE: (916) 263-4700
Kerry HiratsukaTELEPHONE: (916) 591-0210
DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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