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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802037
Report Date: 04/03/2023
Date Signed: 04/03/2023 05:15:38 PM

Document Has Been Signed on 04/03/2023 05:15 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:KRISTIN MCGHIEFACILITY TYPE:
735
ADDRESS:7428 PADDON RDTELEPHONE:
(707) 447-5676
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 4DATE:
04/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Amber Palesi, Co-AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Jill Nakagawa (JN) arrived unannounced to conduct a Required 1-year visit of the facility. LPA was welcomed by DSPs Blaylock and Jacinta Ogutu. There are 4 residents at the facility, but only 2 were present at the time of inspection. Co-Administrator Amber Palesi arrived shortly.

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 and other sharps 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 temperature of 71 F. 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, which was last inspected on July 12, 2022. Facility has submitted a mitigation program plan that has been approved, on 01/20/2022 and an Infection Control Plan.

LPA Nakagawa is requesting the following documents by 04/10/2023 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: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
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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