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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701300
Report Date: 09/26/2023
Date Signed: 09/26/2023 12:03:09 PM

Document Has Been Signed on 09/26/2023 12:03 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:
09/26/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Richelle FrazierTIME COMPLETED:
12:10 PM
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On 9/26/23 Licensing Program Analyst (LPA) arrived at facility announced to continue a pre-licensing inspection. LPA Jensen met with applicant Richelle Frazier and explained the purpose of today's visit.

During a pre-licensing visit conducted on 9/7/23 LPA Jensen requested an Infection Control Plan, the acquisition of an emergency food supply to be kept on site and replacement of some loose bricks in the backyard. All action items were completed as requested.

The facility is observed to be in substantial compliance and the applicant has passed the pre-licensing inspection. A component III presentation was conducted.

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: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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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