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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602881
Report Date: 12/22/2021
Date Signed: 12/22/2021 04:21:09 PM

Document Has Been Signed on 12/22/2021 04:21 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: 4DATE:
12/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Shanta Haines, AdministratorTIME COMPLETED:
11:05 AM
NARRATIVE
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Licensing Program Analyst (LPA), Tiffany Holmes conducted an unannounced case management visit. LPA Holmes introduced herself and was allowed entry into the facility and explained the purpose of the visit to Administrator Shanta Haines.

Today’s visit was regarding the alterations being done on the facility. The facility did not provide any notice to CCL regarding the construction of the new office and client room. LPA Holmes requested copies of the building permit for the facility construction.

Based on today's inspection, deficiencies were observed.
The violation is cited in accordance with California Code of Regulations, Title 22, and is recorded on the attached 809-D (Deficiency) Page.

An exit interview was conducted with Shanta Haines Administrator. A copy of this report, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail. An electronic read receipt verifies receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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 12/22/2021 04:21 PM - It Cannot Be Edited


Created By: Tiffany Holmes On 12/22/2021 at 10:34 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: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2021
Section Cited
CCR
80086

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Alterations to Existing Building or New Facilities:Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. This requirement is not met as evidenced by:
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Facility staff did not notify CCL about construction on the facility. LPA Holmes requested copies of the building permit today on 12/22/2021.
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On 12/22/2021 LPA Holmes arrived at facility and observed alterations being done on the garage of the facility. The facility staff informed LPA they are building an extra room and office. This poses a safety risk to clients in care.
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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: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


LIC809 (FAS) - (06/04)
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