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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801876
Report Date: 04/25/2023
Date Signed: 04/25/2023 12:05:29 PM

Document Has Been Signed on 04/25/2023 12:05 PM - 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 LANEFACILITY NUMBER:
486801876
ADMINISTRATOR:KRISTIN MCGHIEFACILITY TYPE:
735
ADDRESS:851 LA CRUZ LNTELEPHONE:
(707) 447-6393
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 4DATE:
04/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kristin McGhie, AdministratorTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. inspection to this facility and met with Administrator, Kristin McGhie. There are currently 4 residents at the facility, 3 were participating in Day Program at the time of inspection and one additional staff on site.

LPA arrived at the facility and observed hand sanitizer at the entrance. During facility tour on 04/25/23 facility was found to be clean and at a comfortable temperature of 73 F with all exits free from obstruction. Clients' bedrooms, common areas, kitchen & food storage areas were inspected. Two (2) Fire Extinguishers were found to be charged on 07/12/2022 at the time of the visit. There was one Carbon Monoxide Detector. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside the staff room. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All clients' bedrooms have lighting and appropriate furnishings.

LPA inspected the back yard, which has a nice shade patio for clients and staff to enjoy in temperate weather. There was a locked shed in the back for storage of generator and other household goods.

The living room was set up for residents to enjoy TV and games, or visit with friends and family. The staff room was well-organized and staff and resident binders were up-to-date and organized.

There were no deficiencies found at the time of inspection. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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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