486801876-5-21-2024-21-AS-KMOA-D66NXT-20240612105141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486801876
Report Date: 04/04/2024
Date Signed: 05/21/2024 04:51:45 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
03/28/2024 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20240328123933

FACILITY NAME:	A PLACE OF GRACE INC LA CRUZ LANE		FACILITY NUMBER:	486801876
ADMINISTRATOR:	AMBER PALESI		FACILITY TYPE:	735
ADDRESS:	851 LA CRUZ LN		TELEPHONE:	(707) 447-6393
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	6	CENSUS: 4	DATE:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	03:06 PM
MET WITH:	Bianca Fleming,Interim Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not treat resident with respect

INVESTIGATION FINDINGS:

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****Amended to include additional information from later date
Complainant (C1) alleges that staff spoke in a disrespectful way. Staff (S1) states that they are direct with C1 and that C1's personal rights are always respected. A review of narratives for the dates in question and statements taken from witnesses produced no evidence to show a violation of C1’s rights and that staff was disrespectful. Although the allegation may be true, or valid, there is not a preponderance of evidence to prove the violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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