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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803870
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:26:22 PM

Document Has Been Signed on 03/11/2025 04:26 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/
DIRECTOR:		D.MITCHELL/F.HUGHESFACILITY TYPE:
737
ADDRESS:1912 MOOSUP COURTTELEPHONE:
(707) 673-2472
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Female' Hughes, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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Licensing Program Analyst Jill Nakagawa arrived unannounced on 03/11/2025 at approximately 1:10 PM to perform an annual inspection. The facility currently has 4 clients, 3 of whom were participating in day programs at the time of inspection. There were 7 staff members on site.

LPA arrived at the facility and was allowed access. Administrator Female' Hughes was off-site but arrived shortly. LPA toured the facility which was found to be clean and at a comfortable temperature with all exits free from obstruction. Clients' bedrooms, common areas, kitchen & food storage areas, garage and grounds were inspected. Two (2) Fire Extinguishers were fully charged and last inspected on 07/24/2024. Smoke Detectors and Carbon Monoxide Detector were found to be operational during the visit. Facility conducts monthly emergency drills; a Fire Drill was conducted on 01/08/2025 for the NOC shift. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Toxins, sharps and other dangerous items are stored in locked cabinet inaccessible to clients. There is also a locked and secured medication closet with each resident's medications and medical records stored. There was a supply of cleaners, hygiene products and paper products available for clients. All clients' bedrooms have lighting and appropriate furnishings and decorated to reflect each resident's tastes and interests.
There is a signal system on each resident's bedroom door to alert staff for assistance.

Continued on 809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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.- MOOSUP
FACILITY NUMBER: 486803870
VISIT DATE: 03/11/2025
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Continued from 809.....

The grounds were well maintained with lots of fruit trees and flowers and easily accessible pathways. There is a bench with umbrella for outside socialization with family and friends.

The facility was decorated for St. Patrick's Day, and clients were enjoying the great room together, playing music and talking. Another client was in the living room playing video games with staff. All the clients expressed their satisfaction with the facility.

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: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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