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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701127
Report Date: 08/25/2023
Date Signed: 08/27/2023 08:45:49 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/27/2023 08:45 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, 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:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Hope AkubueTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived Unannounced for a inspection. There are no residents in care.

LPA toured the interior and exterior of the facility including the common areas, bathrooms, residents room and garage. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting.

LPA observed the smoke/monoxide alarms to be in working order, and the fire extinguisher to have been serviced.

The fire marshal has cleared the facility to accommodate 4 non- ambulatory residents.

Exit interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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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