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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803870
Report Date: 09/27/2024
Date Signed: 09/27/2024 01:09:12 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/05/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240705095144
FACILITY NAME:A PLACE OF GRACE, INC.- MOOSUPFACILITY NUMBER:
486803870
ADMINISTRATOR:D.MITCHELL/D.MCCARTFACILITY TYPE:
737
ADDRESS:1912 MOOSUP COURTTELEPHONE:
(707) 673-2472
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:4CENSUS: 4DATE:
09/27/2024
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jeanette Berrios, Lead RBT
Dyemond Mitchell, via phone
TIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Licensee is not training staff on the appropriate use of restraints
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
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12
13
Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to deliver findings on the above allegation, Licensee is not training staff on the appropriate use of restraints. LPA met with Lead RBT Jeanette Berrios and Dyemond Mitchell, Administrator via phone.

LPA made observations, reviewed documents and conducted interviews during the course of the investigation regarding the above allegation. LPA found that staff training records were complete and up to date. LPA reviewed the training manual of Crisis Prevention Institute (CPI), the crisis intervention management program used by the Licensee. Records show that training is given by a certified instructor and each staff member must demonstrate competency before being allowed to use the method upon being hired and undergo monthly trainings. LPA reviewed records and video of trainings and found trainings to be compliant with CPI training. Through interviews, LPA found no staff stating they were required to use techniques non compliant with CPI guidelines. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove
the alleged violation(s) did or did not occur, therefore the allegation is
unsubstantiated.



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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