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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801876
Report Date: 08/01/2023
Date Signed: 08/16/2023 09:15:59 AM

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
07/31/2023 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20230731081813
FACILITY NAME:A PLACE OF GRACE INC LA CRUZ LANEFACILITY NUMBER:
486801876
ADMINISTRATOR:KRISTIN MCGHIEFACILITY TYPE:
735
ADDRESS:851 LA CRUZ LNTELEPHONE:
(707) 447-6393
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 4DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Amber Palesi, Future AdministratorTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff did not keep facility free from pests
INVESTIGATION FINDINGS:
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License Program Analyst (LPA) Jill Nakagawa arrived unannouced to conduct a complaint investigation regarding the allegation listed above. LPA toured facility; reviewed pest control reports and interviewed staff and made observations inside of the facility. Upon inspection, mouse droppings were found in 2 bedrooms; the kitchen, living room, bathroom, office and other areas had no evidence of mice. Resident R1 stated that a mouse was caught in R1's room the previous night.

Continue LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
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 3
Control Number 21-AS-20230731081813
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: A PLACE OF GRACE INC LA CRUZ LANE
FACILITY NUMBER: 486801876
VISIT DATE: 08/01/2023
NARRATIVE
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Continued.......

Staff stated that facility has had pest control service out regularly 2/9/23, 4/13/23, and 6/8/23 and has scheduled another visit. Facility has placed mouse traps in different areas through the facility (pictures on file) however has been unsuccessful in eradicating the mice therefore the above allegation is found to be SUBSTANTIATED. Facility is waiting for pest control service to come back to the facility.

Based on LPA's observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation "Staff did not keep facility free from pests " is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 of Chapter 1, is being cited on the attached LIC 9099D.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20230731081813
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: A PLACE OF GRACE INC LA CRUZ LANE
FACILITY NUMBER: 486801876
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2023
Section Cited
CCR
80087(a)
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Buildings and Grounds - The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients... facility. This requirement is not met as evidenced by:
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Facility to ensure that premises are maintained in good repair and a healthful environment at all times. Administrator to obtain an updated assessment of the facility situation regarding mice and proof of an earlier inspection.
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 Based on LPA's observations facility has been having problems with mice and Administrator has placed traps as an effort to eliminate. Facility has place mice traps in different rooms through the facility however has been unsuccessful to catch the mice. (pictures on file)
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Administrator to provide an updated copy of assessment done by pest control and proof to CCL by POC date August 7, 2023.
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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3