<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700317
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:00:57 PM


Document Has Been Signed on 06/09/2022 01:00 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GRACE HOME IIFACILITY NUMBER:
342700317
ADMINISTRATOR:NELSON JACINTOFACILITY TYPE:
740
ADDRESS:9260 LOMA LANETELEPHONE:
(916) 607-6225
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:24CENSUS: 22DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Maria Segurra, AdministratorTIME COMPLETED:
01:28 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On June 9, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct an 1 year required Annual Inspection. LPA met with Maria Segurra, Administrator and informed her the reason for the visit.

Prior to the visit, 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.

Maria and LPA completed the Infectious Control questionnaire with no issues to report.

The administrator certificate is valid and expired 12/12/ 2023. This is a one story complex with a capacity of 24. LPA inspected the interior and exterior of the facility. LPA observed there to be sufficient supply of food in the kitchen. All fire extinguishers were ready for emergency use. Smoke detectors were in place and had fresh batteries. There are bodies of water on the premises. There is a shady area where the residents can sit and mingle with each other.

Per California Code of Regulations, Title 22, No citations were issued.

An exit interview was conducted and a copy of this report was given to Maria.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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 1