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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803679
Report Date: 11/01/2024
Date Signed: 11/01/2024 01:36:40 PM

Document Has Been Signed on 11/01/2024 01:36 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/
DIRECTOR:
JESSE MENDENHALLFACILITY TYPE:
735
ADDRESS:112 NOVATO DRTELEPHONE:
(707) 447-7634
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
11/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Diane McCart, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On 11/01/2024 Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Inspection. LPA was allowed entry by Lead Staff Sharon Hughes, who contacted the Administrator, Diane McCart (DM) who was off-site at the time. Administrator arrived shortly. There are currently 4 clients residing at the facility. LPA toured the facility with DM.

LPA found the facility to be a comfortable temperature of 70 degrees F with all exits free from obstruction. Common areas were clean and orderly, and had homey touches. The kitchen was clean and well organized and was stocked with adequate supply of perishables and non-perishables, as required per Title 22. The four (4) residents' rooms were furnished with the required furniture. Cleaning supplies are locked in the supply closet in the hallway. There is two (2) bathroom which was stocked with handsoap and paper towels. Fire clearance is approved for 4 residents. The fire extinguisher was serviced on 02/20/2024 and was fully charged. There was one carbon monoxide detector which was tested and functioning and a hard-wired central fire detection/sprinkler system. Sharps are locked in the Med-Room cabinet inside the Family Room.
LPA reviewed 4 out of 4 resident files and 4 staff files and found them to be complete.

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

Exit interview conducted with Diane McCart.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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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