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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701127
Report Date: 08/23/2022
Date Signed: 08/31/2022 11:14:26 AM

Document Has Been Signed on 08/31/2022 11:14 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GRACEFUL GIFTS LLCFACILITY NUMBER:
392701127
ADMINISTRATOR:SURVINE, PAMELAFACILITY TYPE:
735
ADDRESS:47 W ACACIA STTELEPHONE:
(999) 222-3333
CITY:STOCKTONSTATE: CAZIP CODE:
95202
CAPACITY: 4CENSUS: 0DATE:
08/23/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Pam SurvineTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Albert Johnson made an announced Pre-licensing Inspection. LPA met with Administrator who assisted with today’s inspection.

LPA met with the facility's Administrator. This facility will be licensed as a 4 bed ambulatory residential facility, LPA was also informed that this will be a Regional Center funded facility.

LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. There are no residents at this time. The kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry rooms are clean and in good repair.

The knives/sharps area will be locked. There is the required furniture, and lighting throughout the facility. Food supplies of non-perishables for a minimum of one week and perishable foods for a minimum of two days will be maintained on the premises.

The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. The centrally stored medication area will be locked at all times.


There are fire extinguisher(s), smoke and carbon monoxide detector(s) in the facility.

Component III was completed.

Continued on 809-C
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GRACEFUL GIFTS LLC
FACILITY NUMBER: 392701127
VISIT DATE: 08/23/2022
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The following issues need to be addressed to meet the requirements of Title 22 and/or Health and Safety Code:
  • Dead bolts on multiple.
  • Common area needs to be furnished.
  • Hot water
  • Posting of required signage
  • Land-line

Administrator will notify Community Care Licensing (CCL) when issues have been resolved and a follow-up visit will be conducted.

An exit interview was conducted and a copy of the report was given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC809 (FAS) - (06/04)
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