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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701300
Report Date: 09/07/2023
Date Signed: 09/07/2023 12:13:30 PM

Document Has Been Signed on 09/07/2023 12:13 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:DIVINE GRACE RESIDENTIALFACILITY NUMBER:
392701300
ADMINISTRATOR:FRAZIER, RICHELLEFACILITY TYPE:
735
ADDRESS:11 W. MAYFAIR AVETELEPHONE:
(209) 242-3382
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 4CENSUS: 0DATE:
09/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Richelle FrazierTIME COMPLETED:
12:30 PM
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On 9/7/23 at approximately 9:45 Licensing Program Analyst (LPA) Maja Jensen arrived at facility for a scheduled pre-licensing visit. LPA Jensen met with Richelle Frazier and explained the purpose of todays visit.
LPA Jensen toured the grounds. There are no bodies of water on the premises. All pathways were observed to be clear of obstruction. There are shaded areas and outdoor furniture available for client use. All window screens are in good repair. There is a garden bed on the side of the house formed by bricks that has loose and missing bricks.

LPA Jensen toured the interior of the facility. The facility has a fire clearance for 4 ambulatory residents. There are 3 bedrooms and 1 bathroom. The facility was observed to be adequately furnished. There is a locked cabinet available for medication and separate locked cabinet available for sharp objects. There is a locked closet where toxins are kept. The facility maintains an adequate supply of linen. There are garbage disposal bins available with tight fitting lids. The appliances were tested and found to be in good working order. The air conditioner and heating system were tested and found to be in good working order. The facility maintains a land line and has internet service. There are various games and activities available for client engagement.

LPA Jensen tested the carbon monoxide detector and the smoke detector and both were found to be in good working order. The facility maintains emergency lighting and a complete first aid kit. The fire extinguisher was last serviced in August of 2023 and is in compliance. There are night lights available in the hallway. The water in the bathroom was 118 degrees Fahrenheit which falls within the required range of 105-120 degrees Fahrenheit.

Continued on LIC 809C....
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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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: DIVINE GRACE RESIDENTIAL
FACILITY NUMBER: 392701300
VISIT DATE: 09/07/2023
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Continued from LIC 809...

LPA Jensen reviewed the emergency disaster plan and Plan of Operation and determined them to be in compliance.

The applicant will need the following items to pass the pre-licensing inspection:

An Infection Control Plan
Replacement of missing garden bricks
Emergency Food Supply

The Licensee anticipates having these action items completed within a week.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC809 (FAS) - (06/04)
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