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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804197
Report Date: 02/26/2025
Date Signed: 02/26/2025 02:19:48 PM

Document Has Been Signed on 02/26/2025 02:19 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/
DIRECTOR:		GOLITZEN, MARIAFACILITY TYPE:
735
ADDRESS:224 E TENNESSEE STTELEPHONE:
(650) 931-5375
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
02/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Maria GolitzenTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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At approximately 12:20PM Licensing Program Analyst (LPA) Stevenson arrived to conduct an unannounced Annual Inspection and was greeted by licensee/administrator Maria Golitzen

Facility is not vendorized and has no clients.
Licensee reports not having current liability insurance and will purchase with the addition of her first client.

At approximately 12:45 PM LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. All 4 client bedrooms are well appointed with the required furnishings and linens as per regulation. The facility provides hygiene items for the clients. Facility is stocked with extra PPE. The home was observed organized and at a comfortable temperature. Fire extinguisher was charged and current. The kitchen was clean and organized. Locking cabinets for centrally stored meds were observed. Locking drawers for sharps were observed. Emergency lights, smoke detectors and carbon monoxide detector were present and operational. Exits were observed to be unobstructed. The living room is homey and comfortable.
An example of planned activities is posted in living room.
The outside area has 1 (1) locked shed with closed paint and hardware. The facility has uncut green grass (technical advisory given)
Bedroom #2 was noted to have access from hallway, as well as, from nearby hallway of bedroom #3 which may represent a personal right/privacy risk (technical advisory given)
Bathroom #2 was observed to have an approximately 1.5" high threshold that may present a tripping hazard.(technical advisory given)
Three (3) steps down from kitchen to living room was observed which may present a tripping hazard (technical advisory given)

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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 2
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: 02/26/2025
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Continued from LIC809

Licensee was asked to notify Community Care Licensing 30 days before clients are accepted.

Technical advisories (TA) issued:
1)Bedroom #2 has two access doors from hallway and hallway adjacent to bedroom #3, licensee was asked to ensure the privacy of client in bedroom #2 from client in bedroom #3.

2)Bathroom #2 has approximately 1.5" high threshold that may present a tripping hazard and licensee was asked to reduce this tripping hazard.

3)Licensee was told to ensure high (green) grass is cut, to reduce fire hazard.

LPA reviewed one (1) of 1 staff whose records were complete.
Copy of updated Surety Bond
Copy of proof of home ownership/mortgage
Copy of LIC500 personal/staff
Copy of designation of responsibility LIC309

There were no deficiencies cited at the time of inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC809 (FAS) - (06/04)
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