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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803679
Report Date: 09/14/2023
Date Signed: 09/14/2023 01:18:41 PM

Document Has Been Signed on 09/14/2023 01:18 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 NOVATO DRIVEFACILITY NUMBER:
486803679
ADMINISTRATOR:JESSE MENDENHALLFACILITY TYPE:
735
ADDRESS:112 NOVATO DRTELEPHONE:
(707) 447-7634
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
09/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Bianca Fleming, Future AdministratorTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced and was greeted by DSP staff, who allowed LPA entry into facility. Bianca Fleming, future Administrator (BF), arrived shortly. There are currently 4 residents residing at the facility. LPA toured the facility with BF.

LPA found the facility to be a comfortable temperature of 74 F with all exits free from obstruction. It was clean and orderly, and had homey touches. The kitchen just received new countertops, which looked nice. The (4) residents' rooms were furnished with the required furniture and bedding. 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. Fire clearance is approved for 4 residents. The fire extinguisher was serviced on July 12, 2023. There was one carbon monoxide detector which was tested and functioning and a hard-wired central fire detection/sprinkler system. The last fire drill was on August 21, 2023. The batteries in smoke detectors were changed on September 7, 2023. All staff are current on 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 Bianca Fleming.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
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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