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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801876
Report Date: 05/21/2024
Date Signed: 05/21/2024 04:39:04 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
03/18/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240318140204
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:
05/21/2024
UNANNOUNCEDTIME BEGAN:
03:52 PM
MET WITH:Bianca Fleming, AdministratorTIME COMPLETED:
04:38 PM
ALLEGATION(S):
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Staff did not safeguard a resident's personal belongings.
INVESTIGATION FINDINGS:
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LIcensing Program Analyst Nakagawa arrived unannounced to conduct an investigation regarding the above allegation.

LPA made observations, conducted interviews and reviewed documents and found no evidence of staff not safeguarding a resident's personal belongings. R1 reported that items were missing from their room on several occasions after room had been cleaned. R1 later found majority of the items in their room. LPA observed that R1 did not keep belongings in an orderly fashion and it would be easy to lose track of them.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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 2
Control Number 21-AS-20240318140204
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: 05/21/2024
NARRATIVE
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Although the allegations may be true, or valid, based upon observations, statements, and records, there is not a preponderance of evidence to prove the allegations are, or are not, true. Therefore, allegations are UNSUBSTANTIATED.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2