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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803087
Report Date: 10/10/2023
Date Signed: 10/10/2023 01:51:36 PM

Document Has Been Signed on 10/10/2023 01:51 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 MONTE VISTA AVENUEFACILITY NUMBER:
486803087
ADMINISTRATOR:BIANCA FLEMINGFACILITY TYPE:
735
ADDRESS:396 W MONTE VISTA AVETELEPHONE:
(707) 447-5051
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 4DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Bianca Fleming, AdministratorTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at approximately 10:50 AM on 10/10/23 at facility to conduct an Annual Inspection. LPA was welcomed by DSP Staff who allowed LPA access. Administrator Bianca Fleming arrived soon after. Administrator showed LPA throughout the facility, which is licensed for 6 ambulatory. There are 4 residents at the facility; two were on site and the other two residents were attending a day program.

The facility has 4 resident bedrooms. There are two bathrooms which were clean and had a supply of soap and paper towels. Toxic cleaning supplies are stored in a locked closet located by the Family 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 the office, along with the medications and client records. The kitchen and dining area were organized and free of clutter. The facility was a comfortable temperature; clean and well maintained. The re-purposed garage is used for resident activities such as exercise and arts and crafts. LPA was shown some wonderful painting projects done by residents. The back yard was clean and had a few chairs. The back fence had recently been replaced. Administrator is hoping to add some sort of shade structure for the following summer.

The Facility has a multi pull station fire alarm with audible/visual notification. There are 8 operational smoke detectors, one operational carbon monoxide detector and one fire extinguisher which was charged and dated July 12, 2023.
Continued........
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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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 MONTE VISTA AVENUE
FACILITY NUMBER: 486803087
VISIT DATE: 10/10/2023
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Continued......

Facility has submitted an Infection Control Plan. Disaster Drills are conducted each month. Last drill was conducted on 9/25/2023.
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Daily medication administration is logged electronically with a program called Behavior Agent.

No deficiencies during today's inspection. No citations issued.
Exit interview conducted with Administrator Bianca Fleming.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
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