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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804157
Report Date: 09/13/2024
Date Signed: 09/13/2024 06:25:13 PM


Document Has Been Signed on 09/13/2024 06:25 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: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:
09/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:Grace Dairo, LicenseeTIME COMPLETED:
03:03 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 for the purpose of conducting a 1 year inspection and met with licensee Mary Grace Dairo. 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.

This visit was scheduled with licensee because the facility doe snot have any residents at this time. This facility is licensed for 4 non-ambulatory, 2 ambulatory residents with a total capacity of 6.

During todays inspection LPA observed :
· fully charged Fire Extinguisher
· 7 smoke detectors and 2 carbon monoxide detector.
. Water temperature was between 105-120 degrees F.
· 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 facility currently has no residents and there were no records to review.

LPA requested the following forms to be sent to LPA by 10/12/2024:

· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
& Copy of Liability Insurance

No deficiencies issued during todays inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
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