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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830782
Report Date: 06/24/2024
Date Signed: 06/24/2024 05:29:59 PM

Document Has Been Signed on 06/24/2024 05:29 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:GRACE'S HOMEFACILITY NUMBER:
496830782
ADMINISTRATOR/
DIRECTOR:		DELA CRUZ, LEONARDOFACILITY TYPE:
735
ADDRESS:937 EVE CTTELEPHONE:
(707) 623-9420
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 4CENSUS: 4DATE:
06/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Leonardo DeLa CruzTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
NARRATIVE
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Licensing Program Analyst (LPA), Alviso is conducting an Required-1 Year inspection, on 6/24/24 at approximately 2:10pm, and met with Administrator Leonardo Dela Cruz. LPA observed two caregivers, Rolando and Josephine, on duty. The facility's nurse arrived during the LPA's 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 5/17/24.

The LPA reviewed four (4) resident files. All clients are on special diets, and each client's care plan reflects this. Files had all required documents.

All staff are trained regarding each clients care plans. Resident P&I monies were maintained as required, and was observed to not mixed with facility funds and/or any other funds.

The LPA reviewed six (6) staff files. All staff have required criminal record clearance. All staff have required training. All staff have first aid and cpr certification.

Facility had a sufficient food supply. Sufficient cleaners/disinfectants, paper products, hygiene products, and linens. Facility had a sufficient supply of furnishings for client use. The facility was observed to be at a comfortable temperature; Facility does have air conditioning and uses fans as well when needed. Sufficient lighting in hallways, bathrooms, resident rooms, and common areas. Hot water was checked at 115.5 degrees Fahrenheit, which is within regulation.

Continued on LIC809C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2024
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 4
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: GRACE'S HOME
FACILITY NUMBER: 496830782
VISIT DATE: 06/24/2024
NARRATIVE
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The following deficiencies were observed and will be cited, see LIC809D.

LPA observed numerous items, wheelchairs, hoyer lift, etc, in the pathway leading to the emergency exit door and ramp. LPA requested the staff to remove the items during the inspection. LPA observed numerous items, wheelchairs, hoyer lift, etc, in the pathway leading to the emergency exit door and ramp. LPA requested the staff to remove the items during the inspection. This fire exit/emergency exit pathway was cleared during the LPA's inspection. Deficiency cited, Fire Clearance 80020(a)- All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

LPA observed the window coverings were broken and had gaps within the blinds where the bathroom shower and/or the clients room could be seen into to. This doesn't allow privacy to the client in the bathroom shower, and/or if wanting privacy in their bedroom. Some of the facility corners, walls, doorways, and doors need cleaning, touching up/repairs, and painting. Deficiency cited, Buildings and Grounds 80087(a)- The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

LPA is requesting the following documents be updated and submitted by 7/24/24.


LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Surety bond
Resident Roster
Copy of current Administrator Certificate.

Deficiencies cited from the California Code of Regulations, Title 22,
Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with the Administrator.
Appeal rights given to the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/24/2024 05:29 PM - It Cannot Be Edited


Created By: Dina Alviso On 06/24/2024 at 04:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRACE'S HOME
FACILITY NUMBER: 496830782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed numerous items, wheelchairs, hoyer lift, etc, in the pathway leading to the emergency exit door and ramp. LPA requested the staff to remove the items during the inspection, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2024
Plan of Correction
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This fire exit/emergency exit pathway was cleared by staff during the LPA's inspection.Administrator to submit proof of training of all staff regarding ensuring fire exits and ramps remain clear of obstruction at all times. POC follow-up due 6/26/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/24/2024 05:29 PM - It Cannot Be Edited


Created By: Dina Alviso On 06/24/2024 at 04:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRACE'S HOME
FACILITY NUMBER: 496830782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed the window coverings were broken and had gaps within the blinds where the bathroom shower and/or the clients room could be seen into to. This doesn't allow privacy to the client in the bathroom shower, and/or if wanting privacy in their bedroom. Some of the facility corners, walls, doorways, and doors need cleaning, touching up/repairs, and painting, the licensee did not comply with the section cited above, which poses a personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Administrator/Licensee to ensure the facility is cleaned, maintained/repaired, painted where needed, and window blinds replaced where they are broken. Submit how the facility will get the needed/required corrections completed, and submit pictures showing corrections. POC due 7/12/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024


LIC809 (FAS) - (06/04)
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