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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803870
Report Date: 03/01/2022
Date Signed: 03/01/2022 10:08:29 AM

Document Has Been Signed on 03/01/2022 10:08 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.- MOOSUPFACILITY NUMBER:
486803870
ADMINISTRATOR:MEETER, MARYFACILITY TYPE:
737
ADDRESS:1912 MOOSUP COURTTELEPHONE:
(707) 673-2472
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Justice King, LeadTIME COMPLETED:
10:07 AM
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Licensing Program Analyst Jill Nakagawa arrived unannounced on 03/01/22 at approximately 9:10 AM to perform annual inspection focusing on Covid-19 protocols. The facility currently has 3 residents.

LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour with staff lead Justice King and 2 additional staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Clients' bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be charged at the time of the visit. Smoke Detectors & Carbon monoxide detector were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in locked hall closet. Dangerous items were stored inaccessible to clients in a cabinet in garage. There was a supply of cleaners, hygiene products and paper products available for clients. All clients' bedrooms have lighting & appropriate furnishings.

Infection Control:
Facility has submitted a mitigation program plan that was approved on 07/06/21. Posters have been placed at entrance, in the bathroom, office, and laundry room, small table with hand sanitizer and other items designated for visitors were placed in the office, and a bottle of sanitizer and tissues was in the living room by the television. There has been no visitors at facility at this time. Staff are screened before coming into work and have temperature checked
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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