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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800152
Report Date: 08/16/2024
Date Signed: 08/16/2024 02:02:00 PM

Document Has Been Signed on 08/16/2024 02:02 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/
DIRECTOR:		PATTON, ALEXIS W.FACILITY TYPE:
735
ADDRESS:362 WINCHESTER STREETTELEPHONE:
(707) 246-6826
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 4DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Alexis Patton, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analysts (LPA) Jill Nakagawa conducted an unannounced Annual Required – inspection for this facility and met with Licensee, Alexis Patton. The facility currently provides care for 4 clients.

LPA continued with a tour of the facility. Facility was found to be clean and at a comfortable temperature. Clients' bedrooms, common areas, kitchen & food storage areas were inspected.1 Fire Extinguisher were found to be last charged on 02/16/2024. 6 Smoke and 1 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 clients' bedrooms have lighting & appropriate furnishings with bedrooms well maintained and cleaned by staff.

Facility conducts and records emergency disaster drills on a quarterly basis. Last drill was conducted on June 3, 2024, which was an evacuation drill. Backyard area is found to be cleared of any debris and emergency exits were unobstructed.

Water at faucets accessible to clients were tested and measured at 119.1 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.
Continued on 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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: 08/16/2024
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Continued from 809....

LPA to continue Annual Inspection at a later date for file review and to check on bathroom renovations.

LPA's conversation with 1 of 3 residents said they enjoyed living at the facility and felt supported, gets to travel, goes to work, and the food was good.

Licensee, Alexis Patton's Administrator Certification is in process for renewal.

LPA requested the following documents be sent to CCL by COB 08/31/2024.

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
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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