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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803087
Report Date: 11/14/2024
Date Signed: 11/14/2024 01:24:53 PM

Document Has Been Signed on 11/14/2024 01:24 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/
DIRECTOR:
MCCART, DIANEFACILITY TYPE:
735
ADDRESS:396 W MONTE VISTA AVETELEPHONE:
(707) 447-5051
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 4DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:37 AM
MET WITH:Diane McCart, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 11/14/2024 at facility to conduct an Annual Inspection. LPA was welcomed by DSP Staff who allowed LPA access. Administrator Diane McCart 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 their 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 of 70 degrees F; clean and well maintained. The re-purposed garage is used for resident activities such as exercise and arts and crafts. The front and back yards had been recently landscaped with xeroscape, walkways and seating areas.

The Facility has a multi pull station fire alarm with audible/visual notification. There are 6 operational smoke detectors, one operational carbon monoxide detector and one fire extinguisher which was charged and last serviced on 07/24/2024. The last fire drill was on 09/30/2024.

4 out of 4 client files and 5 staff files were reviewed and found to be complete.

There were no deficiencies found at the time of inspection. No citations issued.

Exit interview conducted with Administrator. .
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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