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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700941
Report Date: 01/12/2021
Date Signed: 01/12/2021 06:28:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CHIANTI GRACE, LLCFACILITY NUMBER:
392700941
ADMINISTRATOR:LAUREL, MARICARFACILITY TYPE:
740
ADDRESS:9063 CHIANTI CIRCLETELEPHONE:
(209) 688-8058
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 5DATE:
01/12/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary-Carr LaurelTIME COMPLETED:
03:15 PM
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Announced Pre-licensing visit was made by LPA Eric Stone via Facetime on 1/12/2021 with Administrator Mary-Carr Laurel at 2 pm

The facility will be licensed to serve up to 6 residents at any given time. There were 5 residents in care during today's Pre-licensing visit. Observed watching tv, socializing, in rooms and reading magazine

Tour of the facility was conducted via Facetime. The facility has one floor with 4 bed rooms. There is 1 dining areas,1 kitchen, 1 medication room are in kitchen, 2 restrooms and 1 living room. The facility also has a laundry room and cleaning supplies in garage and under sink. hot water was tested and was 108.6, all sinks, showers, and toilets worked.

The Facility has 1 Medication room that is locked and secured along with the first aid kits. Medication room contained all required components at this time. The facility has 3 fire extinguishers (EXP-11/30/21) placed throughout the facility.

There were no deficiencies observed during today's Pre-licensing visit.

LPA Stone completed Component III requirements with the facility.

Report will be emailed for signature and emailed back to LPA Stone
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Eric StoneTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021
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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