<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804128
Report Date: 10/24/2023
Date Signed: 10/24/2023 11:38:53 AM

Document Has Been Signed on 10/24/2023 11:38 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. - MIDWAYFACILITY NUMBER:
486804128
ADMINISTRATOR:DIAZ, FREDDIEFACILITY TYPE:
737
ADDRESS:4767 MIDWAY RD.TELEPHONE:
(707) 447-7634
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 0DATE:
10/24/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Freddie Diaz, AdministratorTIME COMPLETED:
11:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jill Nakagawa arrived at the facility, A Place of Grace, Midway on 10/24/2023 to conduct a pre-licensing inspection with the facility's Administrator Freddie Diaz. .

Tour/Inspection:
The facility has 4 bedrooms and 2 baths and a large, securely fenced yard. The grounds were free of any apparent hazards, fire exits clear. Patio area comfortably furnished. The interior was clean and adequately furnished. Smoke; fire; carbon monoxide all current. Dixon Fire Department cleared the facility for 4 non ambulatory residents with delayed egress and secured and locked perimeter. No bodies of water. No firearms. Locked cabinets for resident and staff records, as well as medications and first aid kit, observed in the office. Kitchen was spacious and clean, adequate supply of dishes and utensils, locked drawer for sharps. Induction stove will be utilized for safety. Food appeared adequate and safe for 4 residents in care. Postings noted to be current and in compliance with regulations. Locked cabinets for cleaning/laundry supplies in hall closet and laundry room cabinets. Required postings were observed at the front door and throughout the facility. 2 exterior sheds will be locked and used for storage. Third shed contains the well for the property.

Comp III was completed with Administrator.

Pre-Licensing is complete and this facility has no apparent deficiencies.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1