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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830782
Report Date: 05/10/2022
Date Signed: 05/10/2022 04:56:26 PM

Document Has Been Signed on 05/10/2022 04:56 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:GRACE'S HOMEFACILITY NUMBER:
496830782
ADMINISTRATOR:DELA CRUZ, LEONARDOFACILITY TYPE:
735
ADDRESS:937 EVE CTTELEPHONE:
(707) 623-9420
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 4CENSUS: 4DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:TIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA), Dina Alviso is conducting an Required 1 Year inspection, and met with Administrator Leonardo Dela Cruz. The inspection is focused on the Infection Control procedures and practices of the facility.

Currently four (4) clients in care. Facility has an approved fire clearance four (4) non-ambulatory clients. The facility has a mitigation plan that was reviewed by the Department. LPA reviewed an incident report recently submitted to the licensing office, and reviewed the client's file.

LPA was screened upon entry into the facility Mitigation policies are in place as required. All visitors are screened upon entering the building; All visitors have their temperatures taken and answer all screening questions. Clients are screened daily, and observed for any changes. Facility was found to be clean, orderly, and at a comfortable temperature. All exits were observed to be free from obstruction. The fire extinguishers were serviced and tagged dated. 7/7/21. Administrator stated he will have the fire extinguishers serviced before they expire. Toxins are stored inaccessible and in locked cabinets. Medications were stored locked making them inaccessible to clients in care. The facility has a large sufficient supply of personal protective equipment (PPE). All postings were up and visible to all as required. LPA observed that the Administrator and all staff had masks on during the LPA's inspection.

No deficiencies cited today.
Exit interview conducted with Administrator Leonardo Dela Cruz.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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