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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803679
Report Date: 09/24/2021
Date Signed: 09/24/2021 11:34:36 AM

Document Has Been Signed on 09/24/2021 11:34 AM - 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 NOVATO DRIVEFACILITY NUMBER:
486803679
ADMINISTRATOR:FICKESS, TIMOTHYFACILITY TYPE:
735
ADDRESS:112 NOVATO DRTELEPHONE:
(707) 447-7634
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Timothy Fickess, AdministratorTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Jill Nakagawa (JN) conducted a 1-year required unannounced inspection and met with Administrator Timothy Fickess. The inspection is focused on the Infection Control procedures and practices of this facility.

All visitors, essential visitors, and staff are screened upon entry. Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents and staff that do not handle medications. All bathrooms had non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment (PPE). LPA left additional N-95 and surgical masks. Administrator, staff, and 1 of the four residents were wearing masks during the LPA's inspection. Mitigation plan was approved by the Department on 07/29/2021. Fire clearance is approved for 4 residents. The fire extinguisher was serviced on July 16, 2021. There was one carbon monoxide detector and a hard-wired central fire detection/sprinkler system. All staff are current on CPR/First Aid Training.

There were 4 residents in care at the facility during this inspection.

No deficiencies during today's inspection.
No citations issued.

Exit interview conducted with the Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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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