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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803087
Report Date: 12/17/2021
Date Signed: 12/17/2021 01:58:09 PM

Document Has Been Signed on 12/17/2021 01:58 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:A PLACE OF GRACE INC MONTE VISTA AVENUEFACILITY NUMBER:
486803087
ADMINISTRATOR:DIAZ, FREDDIEFACILITY TYPE:
735
ADDRESS:396 W MONTE VISTA AVETELEPHONE:
(707) 447-5051
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 4DATE:
12/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Reinalda Lopez, StaffTIME COMPLETED:
02:00 PM
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License Program Analyst (LPA) Jill Nakagawa (JN) arrived unannounced to conduct a Required 1-year visit of the facility on December 17, 2021 at approximately 11:40 AM. LPA was welcomed by Reinalda Lopez (RL), DSP Staff, who toured LPA throughout the facility. Administrator, Freddie Diaz was consulted via phone regarding the Infection Control Inspection. There are 4 clients/residents at the facility.

The facility has 4 resident bedrooms. There are two bathrooms: one for residents/clients and one for staff. They were clean and had a supply of soap and paper towels, as well as postings of instructions for hand-washing. Toxic cleaning supplies are stored in a locked closet located by the Family Room and in the Office. 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 closet. The kitchen and dining area were organized and free of clutter. The facility was a comfortable 72 degrees. The facility was clean and well maintained. There is a re-purposed garage used for client activities. A dining room/seating area located off the kitchen which is used by 1-2 residents or staff at a time.

The facility has a locked medication cupboard which is kept in the office, which is also locked. The Facility has a multi pull station fire alarm with audible/visual notification. Facility has 8 operational smoke detectors, one operational carbon monoxide detector and one fire extinguisher which is charged and dated July 16, 2021.

Facility has submitted a Mitigation Plan, approved on 05/05/2021. There is a single entry/ check-in station at the front door, with screening questions and temperature checks. Temperatures and symptom checks are documented daily for staff, residents and visitors.
Facility has PPE supply stored in a locked closet.

No deficiencies during today's inspection.
No citations issued.
Exit interview conducted with the DSP RL.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
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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