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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802037
Report Date: 03/29/2022
Date Signed: 03/29/2022 03:35:13 PM

Document Has Been Signed on 03/29/2022 03:35 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 PADDON ROADFACILITY NUMBER:
486802037
ADMINISTRATOR:FICKESS, TIMOTHYFACILITY TYPE:
735
ADDRESS:7428 PADDON RDTELEPHONE:
(707) 447-5676
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 4DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Sharon White, DSPTIME COMPLETED:
03:35 PM
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License Program Analyst (LPA) Jill Nakagawa (JN) arrived unannounced to conduct a Required 1-year visit of the facility. LPA was welcomed by Sharon White, DSP. There are 4 residents at the facility.

The facility has 4 client bedrooms. There is one bathroom for clients and one for staff that were inspected. The hot water temperature in measured 118.9 F. Toxic cleaning supplies are stored in a locked closet located in the office/laundry room. Perishable and nonperishable food supplies were sufficient to Title 22 Regulations of 2 days of perishable and 7 days of nonperishable. Knives are kept locked in office drawer. The kitchen and dining area were organized and free of clutter. The facility is well lit with a comfortable ambient temperature. The facility was clean and well maintained.
The facility has a locked medication cupboard located in the office. The Facility has a pull station fire alarm with audible notification. Facility has 1 carbon monoxide alarm and one fire extinguisher.

Facility has submitted a mitigation program plan that has been approved, on 01/20/2022. All staff, clients, & visitors check in with the electronic temperature log and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in a locked closet in the office. Staff have had PPE training.



LPA Nakagawa is requesting the following documents by 04/10/2022 to RPRO:
LIC308-Designation of Facility Responsibility, LIC400-Affidavit Regarding Client/Resident Cash Resources, Change of Administrator Documents

No citations were issued during this visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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