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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002577
Report Date: 01/18/2024
Date Signed: 02/14/2024 10:38:04 AM

Document Has Been Signed on 02/14/2024 10:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SOARFACILITY NUMBER:
045002577
ADMINISTRATOR:YOKOTA, YULIKOFACILITY TYPE:
775
ADDRESS:3760 MORROW LN STE FTELEPHONE:
(530) 898-0813
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY: 6CENSUS: 0DATE:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Jenny Richmond TIME COMPLETED:
02:15 PM
NARRATIVE
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On 1/18/2024 Licensing Program Analyst (LPA) Jaynae Boyles arrived at the facility unannounced to conduct a Required Year Inspection.

LPA conducted an inspection of the Adult Day Program to ensure compliance with Title 22 regulations.

There are three three class rooms, one quiet room, computer room and one large room for activities for participants to use. Each classroom had a plethora of supplies for activities for the classrooms. The bathrooms were in sanitary condition and properly maintained.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to participants. LPA observed the outdoor area and perimeter of the Adult Day Program to be free of clutter and debris and there appeared to be no potential safety hazards to the participants. Smoke detectors and carbon monoxide detector are operational. Fire extinguisher and first aid kit are maintained and ready for emergency use. The facility could not provide documentation of emergency disaster drills for the last 12 months.

LPA checked medication storage and found medication to be locked away and inaccessible to the participants. LPA reviewed (3) resident files and also reviewed five (2) staff files. One staff file was missing a criminal record clearance from the file.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left $100.00 immediate civil penalties were issued

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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 3
Document Has Been Signed on 02/14/2024 10:38 AM - It Cannot Be Edited


Created By: Jaynae Boyles On 01/18/2024 at 01:06 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SOAR
FACILITY NUMBER: 045002577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)(3)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: (3) Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of two staff do not have a criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/25/2024
Plan of Correction
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Adminstrator will complete the criminal records clearance transfer or have the employee obtain a criminal records clearance before the employee continues to work within the facility.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/14/2024 10:38 AM - It Cannot Be Edited


Created By: Jaynae Boyles On 01/18/2024 at 01:06 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SOAR
FACILITY NUMBER: 045002577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82023(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in no disaster drills have been conducted within 12 months out of which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Administrator will create and implement a plan to ensure that disaster drills are conducted every 6 months. Adminstrator will send this plan to the LPA.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3