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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800152
Report Date: 08/20/2021
Date Signed: 08/20/2021 03:00:48 PM

Document Has Been Signed on 08/20/2021 03:00 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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: 3DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Alexis Patton, LicenseeTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Lead Care Staff, Charles Lewis and conducted a tour of the facility. Licensee, Alexis Patton (AP) arrived at the facility later during the visit. The facility currently provides care for 3 clients all of which were present at the time visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Lead Staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher newly purchased in June 2021. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked designated closet in the hallway and in the garage. There was a supply of cleaners, hygiene products and paper products available for clients. All clients bedrooms have lighting & appropriate furnishings.

Infection Control:
Facility has submitted a mitigation program plan which has been approved. Staff and clients are under 70% vaccinated but continue to conduct surveillance testing on a weekly basis for all staff. Clients' medical diagnoses prevent COVID vaccination but Licensee is requesting for Physician's re-assessment and clearance. Posters are readily available to staff and clients for COVID procedures, and facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature on weekly basis.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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