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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803450
Report Date: 06/06/2022
Date Signed: 06/06/2022 01:30:13 PM


Document Has Been Signed on 06/06/2022 01:30 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 MANZANITAFACILITY NUMBER:
486803450
ADMINISTRATOR:FICKESS, LAJUANAFACILITY TYPE:
740
ADDRESS:58 MANZANITA DRTELEPHONE:
(707) 514-7744
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY:4CENSUS: 3DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Amber Palesi, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPA) Jill Nakagawa arrived unannounced to conduct an
Annual Required inspection and met with Amber Palesi, Administrator. Files will be updated to reflect change in Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. At the time of inspection there were 3 staff providing care and supervision for 3 clients.
LPA observed a screening station at the entrance of facility which had hand sanitizer, a thermometer, and a
sign-in sheet for visitor, staff and essential visitors. Visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Staff and client's temperatures are taken at the beginning of every shift each day and documented in a log for residents and employees. LPA conducted a walk-through of the facility with Administrator and observed COVID-19 postings. Staff clean and disinfect the facility daily. High touched surface areas are disinfected after each use.
The facility has a designated visitation area, provides virtual visits and phone calls for family and specialists to
stay in contact with clients. LPA observed a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and gowns stored in the facility staff room. County provided N-95 fit-testing and PPE donning and doffing training.. All of staff wore a face mask during this visit. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks Specific COVID-19 to the California
Department of Social Services which was approved on 5/5/21. Administrator informed of the new Infection Control Plan that is due to CCL by 6/30/22. Exit interview conducted with Administrator,
whose signature on this document confirms receipt.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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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