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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802037
Report Date: 03/07/2024
Date Signed: 03/20/2024 05:18:50 PM

Document Has Been Signed on 03/20/2024 05:18 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:AMBER PALESIFACILITY TYPE:
735
ADDRESS:7428 PADDON RDTELEPHONE:
(707) 447-5676
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 4DATE:
03/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Brianna Fleming, AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analysts (LPAs) Jill Nakagawa and Stefanie Mutialu arrived unannounced to conduct a Required 1-year visit of the facility. LPA was welcomed by Brianna Fleming, Administrator and Roman Price, House Manager. There are 4 residents at the facility, and 4 staff present at the time of inspection.

The facility has 4 client bedrooms. There is one bathroom for clients and one for staff that were inspected. Toxic cleaning supplies are stored in a locked closet located in the office/laundry room. Knives and other sharps are kept in tub in locked office cabinet. The kitchen and dining area were organized and free of clutter. The facility is well lit with a comfortable temperature of 70 F. The common areas of the facility were clean and well maintained. There were holes found in one of the client's bedrooms, which are due to be repaired. A small pellet gun was found unsecured in a resident's room in the facility, which is a violation of California Code of Regulations, Title 22, Division 6.
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 which was tested and operational and one fire extinguisher, which was last inspected on July 12, 2023. Continued on 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ROAD
FACILITY NUMBER: 486802037
VISIT DATE: 03/07/2024
NARRATIVE
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Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given.


LPA requested the following documents to RPRO:
Proof Liability Insurance
Resident Roster
Completed 605's for each resident
Lease Agreement or Control of Property
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2024 05:18 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 03/07/2024 at 04:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: A PLACE OF GRACE INC PADDON ROAD
FACILITY NUMBER: 486802037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2024
Section Cited

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(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:

(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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Based on LPAs observation facility failed to ensure disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients were stored improperly which poses an immediate health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


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