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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602881
Report Date: 11/17/2022
Date Signed: 11/17/2022 05:13:53 PM

Document Has Been Signed on 11/17/2022 05:13 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:
11/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Shanta Haines, AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit to check on the health and safety of residents in care. LPA identified herself and was granted access to the facility by Nyna Drayden, caregiver. LPA met with caregiver Drayden and discussed the purpose of the visit. Administrator Shanta Haines later arrived at the facility and joined the visit.

The visit was initiated due to a self reported incident that involved client #1. LPA toured the facility, and requested and obtained relevant documents maintained by the facility. The Administrator was notified that this visit may require further follow-up. No immediate health and/or safety concerns were observed during today’s visit.

An exit interview was conducted with Administrator Haines. 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: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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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