486800152-7-11-2023-21-AS-DTOA-CTN22X-20230711170128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486800152
Report Date: 07/11/2023
Date Signed: 07/11/2023 05:03:39 PM

Document Has Been Signed on 07/11/2023 05:03 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 HOMES		FACILITY NUMBER:	486800152
ADMINISTRATOR:	PATTON, ALEXIS W.		FACILITY TYPE:	735
ADDRESS:	362 WINCHESTER STREET		TELEPHONE:	(707) 246-6826
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY: 6		CENSUS: 4	DATE:	07/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Alexis Patton, Licensee		TIME COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA's) Tobola and Fowler conducted an unannounced Annual Required – inspection for this facility and was greeted by Lead Staff, Charles Lewis & Antonio Madden. Licensee, Alexis Patton was contacted and arrived later in the visit. The facility currently provides care for 4 clients all of which were present at the time of the inspection. LPA's continued with a tour of the facility with Lead Staff; facility was found to be clean and at a comfortable temperature. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 8/10/2022 at the time of the visit. Smoke and Carbon Monoxide detectors were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food containers labeled with appropriate dates. There was a supply of linens, hygiene products and paper products available for clients located in the hallway. All client’s bedrooms have lighting & appropriate furnishings with bedrooms well maintained and cleaned by staff. LPA conducted a file review for all clients and found 1 out of 4 clients (C1) physician's reports not on record. LPA conducted a review of all staff files and found staff to have updated 1st Aid & CPR certification and annual training on file. Upon review, LPA's found 1 out of 4 staff in need of an updated Health Screening Report. Technical Violation issued. Facility conducts and records emergency disaster drills on a 6-month basis. LPA issued technical violation due to drills not on records. LPA requested for Administrator to conduct drill on a quarterly basis moving forward. Backyard area is found to be cleared of any debris and emergency exits were unobstructed. During the inspection LPA's observed several chemicals and cleaning supplies unsecured and accessible clients in care. Unsecured items including, bleach, paint, isopropyl alcohol located in the bathroom counter and unsecured cabinets in the garage, bathroom and kitchen sinks. In addition LPA's observed a bottle of allergy medication located in client (C1) bedroom. All items were immediately removed and placed in secured designated locked storage locations. Continued onto LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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: 07/11/2023

NARRATIVE

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Water at faucets accessible to clients were tested and measured at 105.2 and 109.3 degrees F and within Title 22 Regulations. Medication is found to be secured in locked closet located in the hallway. A spot medication count was conducted for clients and found to be in order. Technical Assistance issued due to facility needing to reconcile prescription information onto the Centrally Stored Medication Records.

During the inspection, LPA observed mold on client shower curtain. In addition, LPA's found that facility is in need of appropriate lighting in hallway area leading to restroom. Technical Violation and Advisory issued.

Licensee, Alexis Patton's Administrator Certification 6035549735 is valid through 12/2/2023.

LPA requested the following documents be sent to CCL by COB 7/25/2023:

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

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 07/11/2023 05:03 PM - It Cannot Be Edited

Created By: Dominic Tobola On 07/11/2023 at 03:55 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: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having following items; bleach, paint, weed killer, toilet bowl cleaner, isopropyl alchohol accessible to clientsl which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2023
	Plan of Correction
1 2 3 4	Administrator agrees to develop a plan of action to conduct daily audits for staff to ensure all items that constitute danger if accessible to clients in care. Written plan of action to be submitted to CCLD by POC date 7/12/23. In addition, in service training to be conducted for all staff and training to be signed and submitted to CCLD. Training to be submitted to CCLD by POC date 7/25/2023.

Type A

Section Cited

CCR

80087(h)

Building and Grounds

(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having following items; over the counter bottle of allergy medication located in client C1's bedroom accessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2023
	Plan of Correction
1 2 3 4	Administrator agrees to develop a plan of action to conduct daily audits for staff to ensure all items and medication that constitute danger if accessible to clients in care. Written plan of action to be submitted to CCLD by POC date 7/12/23. In addition, in service training to be conducted for all staff and training to be signed and submitted to CCLD. Training to be submitted to CCLD by POC date 7/25/2023.

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: 07/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 07/11/2023 05:03 PM - It Cannot Be Edited

Created By: Dominic Tobola On 07/11/2023 at 04:49 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: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80023(a)

Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above with facility missing updated Emergency Disaster Plan available and posted in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2023
	Plan of Correction
1 2 3 4	Licensee agrees to sumbit an updated Emergency Disaster Plan to CCLD by POC date 7/18/2023. In addition, facility is to submit photo proof of Emergency Disaster Plan form posted/framed in the facility.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 07/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

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