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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803870
Report Date: 02/23/2023
Date Signed: 02/23/2023 01:43:02 PM

Document Has Been Signed on 02/23/2023 01:43 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.- MOOSUPFACILITY NUMBER:
486803870
ADMINISTRATOR:ABBY CARVAJALFACILITY TYPE:
737
ADDRESS:1912 MOOSUP COURTTELEPHONE:
(707) 673-2472
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Dyemond Mitchell, Assistant AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst Jill Nakagawa arrived unannounced on 02/23/2023 at approximately 12:30 PM to perform an annual inspection focusing on Covid-19 protocols. The facility currently has 4 residents. There were 7 staff members on site.

LPA arrived at the facility and had temperature checked and logged into Visitor's Log. During tour 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. 2 Fire Extinguishers were fully charged and last inspected on 08/30/2022 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, sharps and other dangerous items are stored in locked hall supply closet; inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All clients' bedrooms have lighting and appropriate furnishings.

The facility was decorated for the upcoming holiday, and presented a warm homey atmosphere.

Infection Control:
Facility has submitted a mitigation program plan that was approved on 07/06/21. They also have submitted an Infection Control Plan. Posters have been placed at entrance, in the bathroom, office, and laundry room. A 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. Staff and visitors are screened and have temperature checked before entry and/or reporting to work.

There were no deficiencies found at the time of inspection. No citations issued.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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