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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803679
Report Date: 09/09/2022
Date Signed: 09/09/2022 11:16:28 AM

Document Has Been Signed on 09/09/2022 11:16 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Jesse Mendenhall, Admin./House ManagerTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced and was greeted by DSP staff. LPA's temperature was taken and signed the visitor's log. All staff were wearing masks. There are currently 4 residents residing at the facility. Residents are screened and observed for any changes, all information is logged.

House Manager Jesse Mendenhall arrived and toured LPA throughout the facility. The inspection is focused on the Infection Control procedures and practices of this facility.

LPA found the facility to be a comfortable temperature of 73 F with all exits free from obstruction. It was clean and orderly, and had homey touches. The (4) residents' rooms were furnished with the required furniture, and were clean and orderly. Cleaning supplies are locked in the supply closet in the hallway.
There are 2 bathrooms which were stocked with handsoap, paper towels and Covid-19 signage reminding residents and staff to wash their hands. Facility has a sufficient supply of personal protective equipment (PPE). 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 12, 2022. There was one carbon monoxide detector and a hard-wired central fire detection/sprinkler system. All staff are current on CPR/First Aid Training.

The kitchen was stocked with a 2-day supply of fresh food including fresh fruits and vegetables, and a stock of at least a 7-day supply of non-perishables. Sharps are locked in the Med-Room cabinet inside the office.

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

Exit interview conducted with Jesse Mendenhall.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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