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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200251
Report Date: 01/30/2024
Date Signed: 01/30/2024 01:27:36 PM

Document Has Been Signed on 01/30/2024 01:27 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SOCIAL DAY SERVICES PROGRAMFACILITY NUMBER:
019200251
ADMINISTRATOR:LESA MELLIONFACILITY TYPE:
775
ADDRESS:211 JOAQUIN AVENUETELEPHONE:
(510) 483-8000
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 46CENSUS: 28DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Dominique Mellion, AdministratorTIME COMPLETED:
01:35 PM
NARRATIVE
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On 01/30/24 at 11:40AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced required annual inspection and met with administrator (ADM). LPA explained the purpose of the visit with ADM.

During visit, LPA observed a COVID-19 screening station with visitor's log, box of gloves, face masks, hand sanitizer and no touch temperature probe for staff and visitors' use. LPA observed a total of 28 clients in activities rooms with 6 staff wearing face masks at the facility.

At 12:15PM, LPA toured the facility with ADM including but not limited to clients' activity rooms (2), relaxation room, hydration room, locker room, office, bathrooms (2) and kitchen. LPA observed adequate lighting in the facility with room temperature at 68 deg F. LPA observed several clients engaged in morning activities in the main room with 6 staff wearing face masks assisting clients. LPA observed locked storage cabinets for cleaning supplies, disinfectants and clients' medications. Smoke and carbon monoxide detectors were tested operational. LPA observed hot water temperature measured at 119 degrees F in the bathrooms. Indoor passageways were observed free of obstruction. LPA observed facility has designated male and female bathrooms equipped with paper towels with holders, proper hand washing poster and no touch soap dispensers. LPA observed 3 fire extinguishers fully charged located in the kitchen/common areas and last inspected on 02/24/23. Chemical supplies were observed locked and separate from food supplies. Equipment and supplies for clients' personal hygiene were observed available and on site inside the changing rooms.

Continued on next page, LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SOCIAL DAY SERVICES PROGRAM
FACILITY NUMBER: 019200251
VISIT DATE: 01/30/2024
NARRATIVE
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There were activity materials observed inside the activity rooms. Emergency/Disaster plans and contact information were observed posted on the bulletin board in the common area. Emergency exit plans were also prominently displayed along with complaint poster and personal rights. Facility has 3 flashlights available and operational for emergency use. LPA reviewed 5 staff and 5 client files. LPA also interviewed 2 staff and 3 clients.

The following deficiency was observed during visit:
  • Open trash bins in bathrooms/kitchen areas

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/30/2024 01:27 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 01/30/2024 at 12:24 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SOCIAL DAY SERVICES PROGRAM
FACILITY NUMBER: 019200251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82095.5


This requirement is not met as evidenced by:
Deficient Practice Statement
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A licensee shall ensure that infection control practices are maintained as follows
A tissue shall be disposed of in the nearest waste receptacle with a tight-fitting cover immediately after use. Based on observation, the licensee did not comply with the section cited above due to open trash bins in bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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By POC due date, Administrator agreed to purchase new foot operated trashbins to replace open trash bins in bathrooms and kitchen areas.
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:Bennett Fong
LICENSING EVALUATOR NAME:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
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