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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602881
Report Date: 07/29/2022
Date Signed: 07/29/2022 10:45:38 AM

Document Has Been Signed on 07/29/2022 10:45 AM - 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: 4DATE:
07/29/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shanta Haines, AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analysts (LPA) Daniela Huerta, and County of San Diego Nurse Sandra Brackman, conducted an on-site visit. LPA and Nurse identified themselves and discussed the purpose of the visit with Administrator Shanta Haines.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, screening protocols as well as the use of personal protective equipment. During today's visit, Shanta Haines was interviewed and a walk-though of the facility was conducted. A debriefing was conducted with the Shanta Haines at the conclusion of the visit. No deficiencies were issued today.

An exit interview was conducted with the Administrator and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniela Huerta
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
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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