<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800414
Report Date: 02/17/2023
Date Signed: 02/17/2023 01:33:51 PM

Document Has Been Signed on 02/17/2023 01:33 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:CAREMAX, INC. - DELGANADO HOUSEFACILITY NUMBER:
216800414
ADMINISTRATOR:DIZON, AGNESFACILITY TYPE:
735
ADDRESS:786 DELGANADO ROADTELEPHONE:
(415) 507-0955
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 4DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Willie Yang, LicenseeTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 2/17/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Licensee, Willie Yang and Administrator, Agnes Dizon. The facility currently provides care for 4 clients all of which were attending day program at the time of visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Licensee and Administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher located in the garage was found to be last charged on 11/4/2022 at the time of the visit. Smoke and carbon monoxide detectors in client bedrooms and throughout the facility are interconnected and were inspected and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for clients. Food was found to be stored properly with labeled dates and containers to ensure food quality. LPA conducted a sample file review for 4 out of 4 staff and found all staff to have current CPR and 1st Aid certification on file.

Toxins are stored in a locked cabinets located in the garage and found to be secured. There was a supply of hygiene products and paper products available and provided to clients upon request. Facility has sufficient amount of PPE and sanitation supplies including restrooms equipped with paper towel and soap dispensers. All client bedrooms have lighting & appropriate furnishings. Medications are delivered directly to the facility and found to be stored in designated cabinet located in the garage. During the inspection LPA observed 2 out of 2 window screen separating from the frame. However, screen mesh is not damaged or torn and Licensee repaired items during the visit.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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 2
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: CAREMAX, INC. - DELGANADO HOUSE
FACILITY NUMBER: 216800414
VISIT DATE: 02/17/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA was informed that clients are taken on outings frequently with staff and follow proper infection control screening protocols upon return to the facility. LPA observed several exercise equipment, music instruments and activity supplies to keep clients engaged. LPA conducted a sample review of client P&I records. LPA found that clients utilize bank account systems under New Leaf and no longer use cash. P&I funds found to be in order and not commingled.

Administrator, Agnes Dizon's Administrator Certification 6026680735 is currently active and expires on 6/24/2023.

Infection Control:
Facility has completed an Infection Control Plan and submitted CCLD for review. All clients and staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and clients ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature on daily basis or based on change of condition.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 3/3/2022:



LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
Copy of Surety Bond
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2