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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486800152
Report Date: 04/27/2023
Date Signed: 05/12/2023 01:56:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/18/2023 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20230418101544
FACILITY NAME:GRACE CARE HOMESFACILITY NUMBER:
486800152
ADMINISTRATOR:PATTON, ALEXIS W.FACILITY TYPE:
735
ADDRESS:362 WINCHESTER STREETTELEPHONE:
(707) 246-6826
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:6CENSUS: 4DATE:
04/27/2023
UNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Jeanette Webster. Lead StaffTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff not fingerprint associated to the facility providing care and supervision to clients
INVESTIGATION FINDINGS:
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13
***Dated 5/12/2023. This is an amended version of the report created on 04/27/2023***
On 4/27/2023 Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of initiation complaint investigation. LPA interviewed staff, reviewed records and made observations.

Complaint alleges staff not fingerprint associated to the facility providing care and supervision to clients. Based on interview with Licensee, LPA informed that from November 2022 through December 2022, staff S6 was working in the facility for approximately 30-days with a pending background clearance. S6 was providing direct care and supervision to client but was in the presence of cleared staff.

Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/18/2023 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20230418101544

FACILITY NAME:GRACE CARE HOMESFACILITY NUMBER:
486800152
ADMINISTRATOR:PATTON, ALEXIS W.FACILITY TYPE:
735
ADDRESS:362 WINCHESTER STREETTELEPHONE:
(707) 246-6826
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:6CENSUS: 4DATE:
04/27/2023
UNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Alexis Patton, LicenseeTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff falsifying documents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 4/27/2023 Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of initiation complaint investigation. LPA interviewed staff, reviewed records and made observations.

Complaint alleges staff are falsifying documents to clear other staff. Upon on a review of staff records LPA confirmed staff personnel report and all staff providing care to have appropriate criminal background clearances. There were no indications or enough corroborating evidence of facility falsifying fingerprint or background clearance documents for other staff use therefore the allegation is found to be unsubstantiated.
Allegation, staff falsifying documents is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Appeal Rights given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20230418101544
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRACE CARE HOMES
FACILITY NUMBER: 486800152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2023
Section Cited
CCR
87355(e)(2)
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2
3
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5
6
7
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or..
This requirement is not met as evidenced by:
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2
3
4
5
6
7
***Dated 5/12/2023. This is an amended version of the report created on 04/27/2023***
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
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14
Staff without fingerprint clearance had been removed from the facility in December 2022. Licensee provided Updated Guardian Roster to CCLD. Deficiency cleared at the time of visit.
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7
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5
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7
1
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7
1
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7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 21-AS-20230418101544
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GRACE CARE HOMES
FACILITY NUMBER: 486800152
VISIT DATE: 04/27/2023
NARRATIVE
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Allegation, staff not fingerprint associated to the facility providing care and supervision to clients, is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4