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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830782
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:04:55 PM

Document Has Been Signed on 06/20/2023 04:04 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:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Licensee-Glenn VargasTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA), Alviso is conducting an Required-1 Year inspection, on 6/20/23 at approximately 11:35am, and met with Licensee Glenn Vargas, and Administrator Leonardo Dela Cruz. LPA observed two caregivers on duty during the inspection.

Currently four (4) clients in care. Facility has an approved fire clearance four (4) non-ambulatory clients. All client rooms are private. The facility does have a required infection control plan. The facility does have a required emergency disaster plan.

Facility had an evacuation fire drill on 6/14/23, including staff & clients. Clients, 4 out of 4, special diets regarding food are followed per staff interviews, and per LPA's observations during the inspection.

The LPA reviewed five( 5) staff files. Administrator certificate for Leonardo Dela Cruz is current-#6003742735, expires 8/6/2023. All staff have required criminal record clearance. All staff have required training. The LPA reviewed four(4) resident files. Resident files were complete. Resident P&I monies were maintained as required, and not mixed with facility funds/any other funds.

The LPA toured the facility with the Administrator. All exits were unobstructed. The facility's two(2) fire extinguishers were serviced and tagged as required-expires 10/12/23. Facility had six(6) smoke alarms, and all were working properly when checked during the inspection. Facility had two(2) carbon monoxide detectors that were working properly when checked during the inspection. Facility had a first aid kit stored in the kitchen, it did have a required first aid booklet. The facility had a first aid kit, and first aid booklet, in the client transportation vehicle. The facility had a sufficient supply of perishable and nonperishable food.

Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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: GRACE'S HOME
FACILITY NUMBER: 496830782
VISIT DATE: 06/20/2023
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The facility had food, water, and emergency supplies to meet the 72 hour shelter in place requirement. The facility had a sufficient supply of personal protective equipment(PPE) for use as needed. The facility had a sufficient supply of hygiene supplies, cleaning supplies, and paper products for use as needed. The LPA observed the facility to be clean and orderly during the visit. The LPA observed that resident rooms, common areas, hallways, and bathrooms had sufficient lighting for clients in care. Clients rooms had required accommodations per regulations. Facility bathrooms had grab bars for use as needed. Facility had all medications locked up and inaccessible to clients in care as required. Facility had all cleaners/toxins locked up and inaccessible to clients in care as required.

LPA is requesting the following forms be updated and submitted to CCL by 7/7/23:

· LIC 500 -Personnel Report
· LIC 610D - Disaster Plan
· LIC 308 - Designation of Responsibility
· LIC 308 - Copy of Administrator Certificate
· Affidavit Regarding Client Cash Resources
· Copy of Surety Bond in Required Amount
· Infection Control Plan If updated

No deficiencies cited at todays inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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