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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803870
Report Date: 08/17/2023
Date Signed: 08/17/2023 10:40:15 AM

Document Has Been Signed on 08/17/2023 10:40 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:ABBY CARVAJALFACILITY TYPE:
737
ADDRESS:1912 MOOSUP COURTTELEPHONE:
(707) 673-2472
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
08/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dyemond Mitchell, House Manager TIME COMPLETED:
10:40 AM
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    Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to A Place of Grace - Moosup to conduct an inspection and check to see that there was not an uncleared employee working at the facility.

LPA Nakagawa inspected the facility and found it to be clean and well-organized. There were 5 staff on site and 2 staff out with clients. There were 2 clients on site at the time of inspection. The other 2 residents were out in the community (with staff support).

The facility was a comfortable temperature and had an adequate supply of fresh and non-perishable food.

Some sttaff and residents were interacting in activities, while one staff member was participating in trainig, and other staff on site was taking care of administrative tasks.

LPA checked with House Manager and HR Department and found that uncleared individual was not working at A Place of Grace - Moosup or any other of the A PLace of Grace facilities.

No deficiencies found at the time of inspection.
No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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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