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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801876
Report Date: 12/29/2023
Date Signed: 12/29/2023 03:30:23 PM

Unsubstantiated


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
11/09/2023 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20231109130820
FACILITY NAME:A PLACE OF GRACE INC LA CRUZ LANEFACILITY NUMBER:
486801876
ADMINISTRATOR:AMBER PALESIFACILITY TYPE:
735
ADDRESS:851 LA CRUZ LNTELEPHONE:
(707) 447-6393
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 4DATE:
12/29/2023
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jerald DeShawn Waters, Administrator- in- Training, signed by D'Anglea Allen ,RBTTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Staff speak inappropriately to clients in care
Staff did not safeguard clients' personal property
Staff do not ensure transportation services are provided to clients in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to deliver findings for the complaint allegations listed above. LPA met with Jerald DeShawn Waters, Administrator-in-Training.

The allegation that Staff speak inappropriately to clients in care, Staff did not safeguard clients' personal property and Staff do not ensure transportation services are provided to clients in care were investigated.

Continued on 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023
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 5
Control Number 21-AS-20231109130820
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: 12/29/2023
NARRATIVE
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Continued from 9099......


Regarding the allegation Staff speak inappropriately to clients in care: LPA conducted interviews with clients in care and found that there were no residents who had experienced staff speaking to them inappropriately. One resident stated that there was a new staff member and they were not acquainted well yet, and there may have been a misunderstanding, but there were no incidents of staff speaking inappropriately. Additionally, LPA reviewed training records which showed that staff had been trained as per regulation. Review of personnel records indicate that there were no write-ups, deficiencies or disciplinary action against staff in question. LPA also had the opportunity to observe staff and resident interactions and saw no areas of concern at that time. Based on LPA observation, interviews of Staff and residents and record review LPA was unable to substantiate the allegation that Staff speak inappropriately to clients in care.

Regarding the allegation Staff did not safeguard clients personal property: LPA conducted an inspection of client's room (R1) on 11/16/2023 and found belongings unorganized and scattered about making it hard to determine whether there were items missing. Inspection of R1's room on 12/29/23 showed a great improvement in the client's organization of belongings. On 12/29/23 LPA interviewed R1 who stated that there have been no other issues of missing items since room re-organization. Staff interviewed on 12/29/23 stated that R1 had found most of the things they thought were missing. Based on interviews and observation LPA was unable to substantiate that staff did not safeguard clients' personal property.


Continued on 9099- C(2)
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20231109130820
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: 12/29/2023
NARRATIVE
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Continued from 9099-C(1)....

Regarding the allegation that Staff do not ensure transportation services are provided to clients in care, LPA conducted interviews with staff and clients and found that there was no evidence of staff not ensuring transportation services. The incident in question was regarding a missed appointment due to a staff member in charge of transportation becoming ill and the appointment had to be rescheduled for the following day. LPA found that transportation to the rescheduled appointment was provided in a timely manner, therefore the allegation that Staff do not ensure transportation services are provided to clients in care is UNSUBSTANTIATED.

Although the allegations may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED.

No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5