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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804157
Report Date: 08/02/2023
Date Signed: 08/03/2023 09:36:04 AM


Document Has Been Signed on 08/03/2023 09:36 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:GRACE DAIRO CARE HOMEFACILITY NUMBER:
486804157
ADMINISTRATOR:DAIRO, MARY GRACEFACILITY TYPE:
740
ADDRESS:1009 SHERWOOD AVETELEPHONE:
(707) 653-3050
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 0DATE:
08/02/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Mary Grace DairoTIME COMPLETED:
03:05 PM
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) Araceli Canela arrived unannounced for the purpose of conducting a pre-licensing inspection on 08/02/2023 at Grace Dairo Care Home. LPA met with applicant Mary Grace Dairo, who is the licensee and will be the Administrator of this facility. The facility has a fire clearance approval from the City of Vallejo Fire Department for a total capacity of 6 ambulatory residents on 5/16/2023. This facility has a total of 3 bedrooms that will be used by residents, 1 staff office/bedroom, 2 bathrooms, living room, dinning room, kitchen and garage. Backyard has a shed that is used for storage and locked. Licensee will ensure sufficient staffing at all times. Facility understands, they do not have approval for locked perimeter.

During today’s visit LPA observed the following items:
· Lockable separate cabinets for medications, toxins/cleaners, and knives.
· All exits were unobstructed
· Food supply was within regulation
· 2 Fire Extinguisher charged and purchased 5/2023.
· 7 smoke detectors and 1 carbon monoxide detector, were tested and observed operational. Water temperature was 117.7 F and within 105-120 degrees F.
· Complete first aid kit, night-lights, and flashlights for emergency lighting
· Supply of linens, paper products, and hygiene supplies available
· Required furnishings in 3 of 3 resident bedrooms.
. There was plenty of emergency food and water along with emergency backpacks.

The Component III Orientation was completed with licensee.
Pre-licensing is complete with no corrections needed.
LPA will submit the pre-licensing application report to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.
No deficiencies cited
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
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