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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803350
Report Date: 06/23/2022
Date Signed: 06/23/2022 11:38:28 AM

Document Has Been Signed on 06/23/2022 11:38 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CAREPLUSFACILITY NUMBER:
216803350
ADMINISTRATOR:YANG, WEIFACILITY TYPE:
775
ADDRESS:4182-4184 REDWOOD HIGHWAYTELEPHONE:
(415) 225-6868
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 39CENSUS: 7DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Program Director, Agnes DizonTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Careplus Adult Day Program for the purpose of conducting a Required 1-year inspection. LPA met with Program Director, Agnes Dizon and was granted access into the facility. This Adult Day Program is still closed to the outside with the exception of Caremax facilities.

LPA toured the facility with Program Director, Agnes Dizon. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPA toured building and grounds, day activity rooms, kitchen, and bathrooms. All exits are free of obstruction. Smoke detectors and carbon monoxide detectors were found to be operational during the inspection and inspected once a month with the last inspection being conducted in June 13, 2022. Fire extinguishers are fully charged and current while last inspection dated November 2021. Facility has a pull up station that is tested by licensee. Motor vehicles used to transport clients are not at the facility at this time and are inspected to ensure safe operating condition by drivers, program manager, and RND transportation will check quarterly. Toxins were safely stored in a locked cabinet by the back bathroom. Bathrooms were all equipped with wall mounted soap dispensers and individual paper towels. There is a sufficient supply of sanitary products on hand. Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees F in restrooms. Clients provide their own snacks and lunches, but program will supply food for special occasions. There is one large refrigerator available for client food storage. Facility doesn’t administer medications.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the storage office located in the staff room. Staff have had all PPE training required and have been N95 Fit tested.

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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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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: CAREPLUS
FACILITY NUMBER: 216803350
VISIT DATE: 06/23/2022
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LPA requested the following documents to be sent to CCL:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of clients

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was given to the Program Director, Agnes Dizon.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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