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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003708
Report Date: 07/29/2021
Date Signed: 07/29/2021 06:23:43 PM

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:GRACE MANORFACILITY NUMBER:
397003708
ADMINISTRATOR:GRACE MULLENFACILITY TYPE:
740
ADDRESS:641 TRACEY JEAN COURTTELEPHONE:
(209) 836-9489
CITY:TRACYSTATE: CAZIP CODE:
95377
CAPACITY:6CENSUS: DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:AdministratorTIME COMPLETED:
11:13 AM
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LPA Arlene Garcia arrived at the facility at 10:35am. LPA called facility to complete the Gateway Questions and received no answer. LPA attempted to conduct an unannounced Annual Inspection. LPA rang the door bell and knocked multiple times. Blinds were partially closed so LPA could not see into the facility. LPA observed no COVID or Licensing Forms posted at entrance.

LPA called Administrator AD, Grace Mullen. at 209-836-9489. Call went to voicemail. LPA left a detailed voicemail for Administrator explaining the purpose of the call. LPA requested a call back. LPA waited at the facility for 30 minutes but received no response.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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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