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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700771
Report Date: 02/23/2022
Date Signed: 02/23/2022 03:42:46 PM

Document Has Been Signed on 02/23/2022 03:42 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GRACE CARE HOMEFACILITY NUMBER:
342700771
ADMINISTRATOR:PALAFOX LAPID, GRACIAFACILITY TYPE:
740
ADDRESS:7708 RUDYARD CIRCLETELEPHONE:
(916) 692-8063
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 4DATE:
02/23/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Grace Palafax, AdministratorTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Williams arrived at the facility unannounced on 02/23/2022 to discuss regulations and licensing processes that administrator was previously unsure about. LPA met with Administrator Gracia Palafox and explained the purpose of the visit. Prior to initiating visit LPA completed daily self-screening questionnaire to confirm no symptoms of COVID-19, LPA applied hand sanitizer and wore N-95 respirator.

LPA discussed the eviction process with administrator and went over regulations pertaining to eviction notices. LPA also provided Administrator with detailed instructions on how to produce an eviction notice. LPA and administrator discussed situation of resident who is late on multiple rent payments.

A copy of this report left at facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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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