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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604432
Report Date: 10/15/2021
Date Signed: 10/15/2021 11:11:43 AM

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:HOUSE OF GRACE FOR SENIOR CAREFACILITY NUMBER:
374604432
ADMINISTRATOR:PENOLA, HELENITA B.FACILITY TYPE:
740
ADDRESS:971 RUTGERS AVE.TELEPHONE:
(619) 407-7072
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:6CENSUS: 0DATE:
10/15/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Henelita PenolaTIME COMPLETED:
11:42 AM
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Licensing Program Analyst (LPA) Kennedy made a visit to the facility as a follow-up to a visit on 9-30-21.

During today's visit LPA toured the facility and observed the water temperature was within the required range; ; applicant ordered a first aid manual that meets requirements; non-discrimination policy has been posted; and debris has been removed form the yard.

The applicant has been in contact with the insuring agency to obtain the required liability insurance.

The applicant shall contact the Centralized Application Unit (CAU) for completion of this pending facility application.

An exit interview was conducted with Henelita Penola, Applicant. A copy of this report along with Licensee Rights (LIC9058 01/2016) was provided to Ms. Penola via email. An electronic response confirms the documents were received.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna KennedyTELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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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