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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803350
Report Date: 08/28/2023
Date Signed: 08/28/2023 09:42:01 PM

Document Has Been Signed on 08/28/2023 09:42 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, 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: 30DATE:
08/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Program Director, Agnes DizonTIME COMPLETED:
02:15 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
Licensing Program Analyst (LPA), Alviso arrived unannounced at Careplus, Adult Day Program, on 8/28/23 at approximately 10:50am, to conduct a Required- 1 year inspection. LPA met with Program Director, Agnes Dizon and was granted access into the facility. There are thirty(30) clients attending program services today, 8/28. Administrator Yang arrived a short time later.

Facility is fire cleared for thirty-nine(39) clients, which includes five(5) non-ambulatory. Facility program doesn't administer medications. Clients provide their own snacks and lunches, and the program provides food on special occasions. LPA reviewed a sample of records. Five(5) client files. Five(5) staff files. Ensure all staff are trained in the emergency disaster plan and the facility's infection control plan.

LPA toured the facility with Program Director Agnes. Hot water was checked at 111.5 degrees Fahrenheit. All exits were unobstructed. All smoke alarms, which include carbon monoxide checks, were all working properly during the inspection. All fire extinguishers, six(6), were serviced and tagged as required-expires 11/4/23. The bathrooms were all checked and found to be clean, with a sufficient supply of soap and paper towels, The facility was observed to be clean and orderly during the inspection. There is a refrigerator for clients snacks and lunches to be stored if needed. There is a staff kitchen/break room which was clean and orderly during the inspection. There is an outside patio area for clients to use and for outside activities. Toxins, disinfectants were locked up and secured, inaccessible to clients in care. Facility has sufficient supply of cleaners, sanitizing products, paper products, and personal protective equipment(PPE) supplies.

LPA requested the following documents to be sent to Licensing by 9/28/23.
LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Surety Bond-if handling client cash
Emergency Disaster Plan (LIC 610D)-review and update as/if needed- submit a copy
Infection Control Plan-update as needed- submit

No deficiencies cited during today's visit. Exit interview conducted with Program Director Agnes Dizon.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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 1