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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602881
Report Date: 01/12/2023
Date Signed: 01/12/2023 12:19:17 PM

Document Has Been Signed on 01/12/2023 12:19 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:A PLACE OF GRACE INC CANTON DRIVEFACILITY NUMBER:
374602881
ADMINISTRATOR:HAINES, SHANTAFACILITY TYPE:
735
ADDRESS:7312 CANTON DRTELEPHONE:
(619) 467-7367
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY: 6CENSUS: 3DATE:
01/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jamie Duey- Toscano, CaregiverTIME COMPLETED:
10:05 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced case management visit.

LPA identified herself and was granted access to the facility by Jamie Duey- Toscano, Caregiver. LPA met with caregiver and discussed the purpose of the visit.

The visit was initiated due to a complaint from July of 2021. LPA toured the facility. No immediate health and/or safety concerns were observed during today’s visit. On July. 23, 2021 the facility provided LPA Holmes an Individual Program Plan (IPP) for Client 1 (C1) that was dated 2016. Recently LPA received an updated IPP for C1 that was dated 2022. The facility is being cited during today's visit due to not having an updated IPP for the client during the 2021 visit.

An exit interview was conducted with Jamie Duey- Toscano, Caregiver. A copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided to the facility at the conclusion of the visit. The signature below confirms receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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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Document Has Been Signed on 01/12/2023 12:19 PM - It Cannot Be Edited


Created By: Tiffany Holmes On 01/09/2023 at 04:17 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: A PLACE OF GRACE INC CANTON DRIVE
FACILITY NUMBER: 374602881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited
CCR
80068.2(b)(1)

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If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that:(1) The needs appraisal or IPP is not more than one year old.This requirement is not met as evidenced by:
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Licensee will submit a POC of a trainig for staff on IPP dates and renewals. Licensee will also observe all client files to make sure they are all up to date by POC due date of 01/20/2023.
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On 07/23/2021 LPA observed 1 IPP out of 4 to not be updated and was dated 2016. This poses a potential risk to clients in care
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POC will be submitted with copies of all documents such as staff sign in sheet and any documents used for training purposes.

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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.
SUPERVISOR'S NAME:Simon Jacob
LICENSING EVALUATOR NAME:Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023


LIC809 (FAS) - (06/04)
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