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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804222
Report Date: 07/01/2024
Date Signed: 07/01/2024 01:56:06 PM

Document Has Been Signed on 07/01/2024 01:56 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. HEMLOCKFACILITY NUMBER:
486804222
ADMINISTRATOR/
DIRECTOR:		FLEMING, BIANCAFACILITY TYPE:
735
ADDRESS:365 HEMLOCK STREETTELEPHONE:
(707) 447-7634
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 0DATE:
07/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:David and Sally Price, LicenseesTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived and met with Licensees David and Sally Price. The purpose of this visit is to conduct a Pre-Licensing inspection. The fire clearance has been approved for 4 adults.

The facility is a one story home with 3 bedrooms for residents, livingroom, family room, 2 bathrooms and kitchen. The grounds of the facility were fenced and there was a shaded area available for residents use. There were no accessible bodies of water or firearms. The fire extinguisher was last inspected on 07/12/2023 and fully charged. There were 4 Smoke and 1 carbon monoxide detector which were tested and appeared to be operational. An emergency disaster plan was submitted, and the applicant has identified at least two evacuation locations.

LPA observed locked cabinets for sharps and medications. Kitchen was clean and well-equipped with an adequate supply of dishes and utensils. Refrigerator was clean, with perishable and non-perishable foods. Two additional refrigerators were housed in outdoor shed. Bathrooms had slip mats and grab-bars for resident safety. Hand washing supplies and paper products were available in sinks used by residents. Water temperature was between 105-120 degrees F, which is within regulation. A tour of residents' bedrooms was conducted and bedrooms inspected have lighting & appropriate furnishings and linens.
LPA observed the following postings: personal rights, emergency disaster drills, staff roster, activity poster and menu and the Let Us Know Complaint poster.

LPA conducted a COMP 3 with applicants; some of the following items were discussed: Administrator Qualifications, Reporting Requirements, Maintenance
Continued on 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: A PLACE OF GRACE, INC. HEMLOCK
FACILITY NUMBER: 486804222
VISIT DATE: 07/01/2024
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Continued from 809...

and Operation, Personal Accommodations, Criminal Background clearance.

LPA found no concerns. There were no deficiencies found at the time of inspection. No citations.


This pre-licensing is complete. LPA will submit the pre-licensing reports to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. A copy of the report was given to the Applicant.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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