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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804128
Report Date: 08/15/2024
Date Signed: 08/15/2024 03:56:51 PM

Document Has Been Signed on 08/15/2024 03:56 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. - MIDWAYFACILITY NUMBER:
486804128
ADMINISTRATOR/
DIRECTOR:
DIAZ, FREDDIEFACILITY TYPE:
737
ADDRESS:4767 MIDWAY RD.TELEPHONE:
(707) 447-7634
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 2DATE:
08/15/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Assistant Administrator Kristin McGhieTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived at the facility, A Place of Grace, Midway on 08/15/2024 to conduct a post-licensing inspection with the facility's Assistant Administrator Kristin McGhie. The facility currently has 2 residents. At the time of inspection there were 4 staff members.

The facility has 4 bedrooms and 2 baths and a large, securely fenced yard. The delayed egress door was operational. The grounds were free of any apparent hazards, fire exits were clear. Patio area is shaded and comfortably furnished. The interior was clean and furnishings provided a homey feel. Locked cabinets for resident and staff records, as well as medications and first aid kit, observed in the secured office. Sharps for kitchen are also locked in the medication cabinet in the secured office. Kitchen was spacious and clean, adequate supply of dishes and utensils; Induction stove used for safety. There was an ample supply of perishable and nonperishable foods, appropriately labeled and dated. There are locked cabinets for cleaning/laundry supplies in hall closet and in laundry room. Required postings were observed at the front door and throughout the facility. 2 exterior sheds were locked and used for storage. Third shed contains the well for the property.

Residents remarked that the staff was good and they liked the facility.

No deficiencies found at the time of inspection. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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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