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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803870
Report Date: 12/29/2023
Date Signed: 12/29/2023 11:02:00 AM

Document Has Been Signed on 12/29/2023 11:02 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:D.MITCHELL/D.MCCARTFACILITY TYPE:
737
ADDRESS:1912 MOOSUP COURTTELEPHONE:
(707) 673-2472
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
12/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Dyemond Mitchell via phone,
Jeanette Berrios, Lead RBT 		TIME COMPLETED:
11:05 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 ensure that regulation 80087(g) of Title 22 is being followed.

LPA Nakagawa inspected the facility with Lead RBT Jeanette Berrios and found it to be clean and well-organized. There were 5 staff on site. There were 3 clients on site at the time of inspection. One resident was isolating due to testing positive for Covid. Staff were in masks and PPE was used when providing services to the resident. Proper donning and doffing and disposal of used PPE was observed.

The facility was a comfortable temperature and had an adequate supply of fresh and non-perishable food. The kitchen was inspected for any unlocked sharps and found none. All sharps were stored in a locked cabinet outside of kitchen area and inaccessible to residents as per Title 22, 80087(g).

No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2023
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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