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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800152
Report Date: 08/03/2022
Date Signed: 08/03/2022 03:47:38 PM

Document Has Been Signed on 08/03/2022 03:47 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Alexis Patton, LicenseeTIME COMPLETED:
04:00 PM
NARRATIVE
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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 Licensee, Alexis Patton. The facility currently provides care for 4 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 Licensee; 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 was purchased June 2021 and requires inspection or recharge. 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 and linen supplies. Water temperature was measured at faucets accessible to clients and measured between 105.1 and 105.2 degrees F which is within regulation. 1st Aid & CPR certification for staff was reviewed and found to be current.

Infection Control:
Facility has submitted Infection Control Plan for review. 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. All staff and clients have received full vaccination and boosters and are observed for symptoms and temperature on a daily basis.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/03/2022
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Alexis Patton's Administrator certification 6035549735 is currently pending with a receive date of 3/15/2022.

LPA requested the following documents be sent to CCL by COB 8/17/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Licensee Certificate(s)
Copy of Certificate of Liability Insurance

Exit interview conducted with facility Licensee, whose signature on this document confirms receipt.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/03/2022 03:47 PM - It Cannot Be Edited


Created By: Dominic Tobola On 08/03/2022 at 03:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRACE CARE HOMES
FACILITY NUMBER: 486800152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 expired fire extinguishers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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Licensee agrees to have fire extinguisher inspection/charge completed. Photo of corrections to be sent to CCLD by POC due date 8/10/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


LIC809 (FAS) - (06/04)
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