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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701300
Report Date: 09/12/2024
Date Signed: 09/12/2024 02:45:58 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/12/2024 02:45 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DIVINE GRACE RESIDENTIALFACILITY NUMBER:
392701300
ADMINISTRATOR/
DIRECTOR:		FRAZIER, RICHELLEFACILITY TYPE:
735
ADDRESS:11 W. MAYFAIR AVETELEPHONE:
(209) 242-3382
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 4CENSUS: 0DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:02 PM
MET WITH:Richelle FrazierTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived announced 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 have been serviced.

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

Exit interview
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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