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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486801876
Report Date:
07/27/2022
Date Signed:
07/27/2022 10:34:11 AM
Document Has Been Signed on
07/27/2022 10:34 AM
- 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:
A PLACE OF GRACE INC LA CRUZ LANE
FACILITY NUMBER:
486801876
ADMINISTRATOR:
HICKS, TERRANCE
FACILITY TYPE:
735
ADDRESS:
851 LA CRUZ LN
TELEPHONE:
(707) 447-6393
CITY:
VACAVILLE
STATE:
CA
ZIP CODE:
95687
CAPACITY:
6
CENSUS:
4
DATE:
07/27/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Eileen Addamo, DSP2
TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection and deliver PPE supplies. Facility was clean and a compfortable temperature. There was one staff member and 2 residents on the premises at the time of inspection.
LPA reminded staff and managers to please report all Covid positive cases to the Department.
LPA learned that the residents will be going on a cruise to Ensenada for 4 days at the beginning of August (4 -8). That should be a wonderful experience and an awesome opportunity.
NO deficiencies were observed at the time of inspection.
NO citations issued.
SUPERVISORS NAME
:
Kimberley Mota
LICENSING EVALUATOR NAME
:
Jill Nakagawa
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/27/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2022
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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