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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804197
Report Date: 03/08/2024
Date Signed: 03/08/2024 02:32:08 PM

Document Has Been Signed on 03/08/2024 02:32 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:TRINITY GRACE HOME LLCFACILITY NUMBER:
486804197
ADMINISTRATOR:GOLITZEN, MARIAFACILITY TYPE:
735
ADDRESS:224 E TENNESSEE STTELEPHONE:
(650) 931-5375
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
03/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Maria Golitzen, AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived announced to conduct a pre-licensing inspection and was greeted by Maria Golitzen, Administrator.

At approximately 11:00am LPA and Administrator toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed respective emergency shut off valves for electricity, gas, and water. Admin will update facility sketch with location of emergency shut off valves and send to CCL once updated.

Facility is a one story residence with three bedrooms, a master bedroom with private full bathroom, and one common full bathroom, dining room, family room, living room, and a large backyard. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Water temperatures read at 110.5, 106.2 and 105.9 degrees F, respectively in the kitchen and bathrooms which is within regulation of 105 & 120 degrees F.

Facility has sufficient items used for cooking and eating. Facility has a locked cabinet in the kitchen that will house centrally stored medication. Cleaning supplies and toxins will be stored in kitchen under the sink in locked cabinet. Laundry cleaning supplies are stored in a locked cabinet the garage. Locked closet in hallway contains toxins and extra toiletries. Facility has areas inside and outside for visiting and activities.

Facility received an approved fire clearance dated September 25, 2023 that allows for up to four [4] ambulatory residents. LPA observed fire extinguisher located in kitchen was last serviced August, 15, 2023.

Maria Golitzen Administrator Certificate 6047820735 expires 3/23/2024, Admin advised that she has submitted her renewal and is awaiting the Pending list. LPA advised certificate must be maintained current as facility must have an active Administrator at all times.

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SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TRINITY GRACE HOME LLC
FACILITY NUMBER: 486804197
VISIT DATE: 03/08/2024
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Continued from 809...

LPA and Administrator reviewed Emergency Disaster Plan and Infection Control Plan. Admin advised that they will use current car for transportation until van indicated on current Emergency Disaster Plan is purchased. Keys will be made available to the staff once hired. Also, facility will purchase back up generator. Once purchased facility will update Emergency Disaster plan.

LPA observed required posters for residents rights and required licensing posters.

LPA will submit facility's application for approval.

Comp III reviewed and exit interview conducted with Administrator and a copy of this report given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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