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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801876
Report Date: 04/04/2024
Date Signed: 04/04/2024 03:19:48 PM

Document Has Been Signed on 04/04/2024 03:19 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/
DIRECTOR:
AMBER PALESIFACILITY TYPE:
735
ADDRESS:851 LA CRUZ LNTELEPHONE:
(707) 447-6393
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 4DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Bianca Fleming, Interim AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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Licensing Program Analyst (LPAs) Jill Nakagawa and Stefanie Mutialuconducted an unannounced Annual Required – 1 yr. inspection to this facility and met with Administrator Bianca Fleming. There are currently 4 residents at the facility, all were participating in Day Program at the time of inspection and one staff on site. Administrator and House Manager arrived 10 minutes later.

During facility tour on 04/04/24 facility was found to be organized, free of clutter 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 07/12/2023 at the time of the visit. There were 2 carbon monoxide detectors that were tested and functional. Smoke detectors were checked on 4/1/24 and found to be operational. 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. There is a new resident cat named Bella, who the residents enjoy caring for. LPAs inspected the back yard, which was free of debris. There is a patio cover providing shade. 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: 04/04/2024
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.

LIC809 (FAS) - (06/04)
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