374602881-1-12-2024-08-AS-CLOZ-CZEVFX-20240112152439

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602881
Report Date: 01/12/2024
Date Signed: 01/12/2024 03:25:38 PM

Document Has Been Signed on 01/12/2024 03:25 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	A PLACE OF GRACE INC CANTON DRIVE		FACILITY NUMBER:	374602881
ADMINISTRATOR:	HAINES, SHANTA		FACILITY TYPE:	735
ADDRESS:	7312 CANTON DR		TELEPHONE:	(619) 467-7367
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY: 6		CENSUS: 4	DATE:	01/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Justin Felan, Administrator		TIME COMPLETED:	03:30 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	Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by Administrator Justin Felan. LPA discussed the purpose of the visit with Administrator Felan. According to the facility’s license, there may be a maximum of six (6) clients all of whom may be ambulatory in at any given time at the facility site; and staff shall be awake at all times. During today’s inspection, the facility’s current census is 4 client’s living at the facility. There were two (2) client’s present at the facility site, but left during the inspection. Upon one client's return the client went to rest. LPA, accompanied by Administrator Felan, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 71 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: kitchen sink measured at 117 degrees F; sink in restroom #1 delivered hot water at 115 degrees F; sink in restroom #2 delivered hot water at 111.6 degrees F; and laundry room delivered hot water at 112.3 degrees F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present, and all safely stored. There were no toxic chemicals/poisons accessible to clients. LPA inspected and found that medications were properly labeled, as required, and stored in a locked cabinet. The facility maintained medication system which LPA reviewed. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: A PLACE OF GRACE INC CANTON DRIVE	FACILITY NUMBER: 374602881
	VISIT DATE: 01/12/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per Administrator Felan, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. A fire extinguisher was present (01) and serviced within the last 12 months. First aid kit(s) were complete and readily accessible.

LPA interviewed staff, and reviewed staff and client records. During today’s visit there were 2 clients on the facility premise. LPA was unable to interview client as they were resting and second client left the premise. Interview did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

There were no deficiencies observed or cited during today's annual inspection.

An exit interview was conducted with Administrator Justin Felan to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Administrator Felan to submit a current Designation of Administrative Responsibility LIC 308, Emergency Disaster Plan LIC 610-D, and Residential Infection Control Plan LIC 9282 (6/23), to the licensing office within 10 business days. Personnel Report LIC 500 was updated. Forms are available at www.ccld.ca.gov.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC809 (FAS) - (06/04)

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