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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602881
Report Date: 01/03/2025
Date Signed: 01/03/2025 12:58:27 PM

Document Has Been Signed on 01/03/2025 12:58 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 DRIVEFACILITY NUMBER:
374602881
ADMINISTRATOR/
DIRECTOR:		HAINES, SHANTAFACILITY TYPE:
735
ADDRESS:7312 CANTON DRTELEPHONE:
(619) 467-7367
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY: 6CENSUS: 3DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Administrator Salvador AntonTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Arian Golbakhsh and Amy Rodgers conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit to DSP Sholanda Jones. Administrator Salvador Anton joined shortly after. The facility's license shows a maximum capacity of six (6) ambulatory clients. During today’s inspection there were three (3) clients in care.
 
LPAs and Administrator Anton 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, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Bathroom sink was 111.4F. 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 client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to clients, as well as toxic chemicals or poisons. No pools or bodies of water exist on the premises. Per Administrator Anton, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. The fire extinguisher was serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

[Continued on LIC 809-C]
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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 01/03/2025 12:58 PM - It Cannot Be Edited


Created By: Arian Golbakhsh On 01/03/2025 at 11:40 AM
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: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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An unsecured cup of medication was observed on the dining table upon entry into the facility. Based on observation and interviews the licensee did not comply with the section cited above in all clients in care (3 of 3) which poses a potential health and safety risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
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Licensee agrees to complete training for self and staff regarding proper storage and administration of medications by POC date. Licensee will provide confirmation of training via email to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jennifer Lott
LICENSING EVALUATOR NAME:Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


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: 01/03/2025
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[Continued from Page 1 of LIC 809]

LPAs interviewed two (2) staff and two (2) clients, and interviews did not reveal any licensing or regulatory concerns. LPAs reviewed facility records which contained required documents. Confidential records were stored in locked areas. Upon entry into the facility, LPAs noticed unlabeled medications sitting on the kitchen table. Interview with DSP staff revealed that a client likes to take their medication while eating. Aside from that dose, medications were labeled, as required, and stored in locked areas.

A deficiency was observed during today's inspection and cited per Title 22 regulations on the attached LIC 809-D. An exit interview was conducted with Administrator Anton to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Their signature below confirms receipt of these documents.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
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