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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701127
Report Date: 09/12/2022
Date Signed: 09/12/2022 11:05:53 AM

Document Has Been Signed on 09/12/2022 11:05 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:
09/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:P. SurvineTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Albert Johnson arrived announced to complete a pre licensing inspection. LPA met with Pam Survine.

Currently there are no clients at the facility. Fire clearance was granted on 3/23/22 for 4 ambulatory clients.

Facility was inspected both indoors and outdoors. LPA inspected proposed bedrooms, bathrooms, kitchen, garage, and common areas. Outdoor exits are clear and accessible. There are 2 floors to this facility. 5 resident bedrooms, a staff room and 4 and 1/2 bathrooms were observed.

Hot water temperature was measured at 116.5 degrees. Smoke detectors and carbon monoxide detectors were checked and operational. Fire extinguisher indicator revealed a full charge. Kitchen is clean sanitary, and in good repair. There will be locked areas for cleaning supplies, sharps, medications and toxins.

Component III was completed. The land line is (209) 323-4718

The applicant has passed the pre-licensing inspection.

LPA will notify the Central Applications Unit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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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