<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802037
Report Date: 05/17/2022
Date Signed: 05/17/2022 02:01:30 PM

Document Has Been Signed on 05/17/2022 02:01 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:MITCHELL, DYEMONDFACILITY TYPE:
735
ADDRESS:7428 PADDON RDTELEPHONE:
(707) 447-5676
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 4DATE:
05/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:David Price, LicenseeTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Nakagawa conducted an unannounced case management inspection to follow up on a self reported incident report submitted to Community Care Licensing. LPA was greeted by S1 who contacted David Price, Licensee. The purpose of this case management inspection is to obtain additional information regarding incident involving R1 on 04/21/22 and a medication error. LPA made observations, reviewed records and conducted interviews.

LPA found the facility to be neat and clean and a comfortable temperature. 3 of the 4 residents were on site. The 4th resident was attending day program.

CCL received a self reported incident report on R1 being detained by police. LPA reviewed resident records and found the issue was resolved. Resident records indicate the rules and requirements that R1 must adhere to while in residency at Paddon, and it was discussed which staff will be responsible for oversight. .

LPA also reviewed medication protocols with staff; insuring that guidelines for dispensing medications are followed.

No citations issued during today's inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1