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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803350
Report Date: 08/21/2024
Date Signed: 08/21/2024 11:08:55 AM

Document Has Been Signed on 08/21/2024 11:08 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CAREPLUSFACILITY NUMBER:
216803350
ADMINISTRATOR/
DIRECTOR:		YANG, WEIFACILITY TYPE:
775
ADDRESS:4182-4184 REDWOOD HIGHWAYTELEPHONE:
(415) 225-6868
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 39CENSUS: 29DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Program Director, Agnes Dizon TIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Program Director, Agnes Dizon. Facility is an Adult Day Program for Adults with Disabilities. Facility has an approved fire clearance and capacity for 39 Clients, of which 5 can be Non-Ambulatory. Upon arrival, LPA was informed that there were 29 clients attending Day Program and 10 staff members on-site.

At approximately 9:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:00AM, LPA conducted a walk-though of the facility with Program Director. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 4 activity rooms, 3 bathrooms and common areas. Facility has an Infection Control plan on file. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, hygiene products and paper products available for clients. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Per Program Director, clients bring their own snacks and lunches to program. Facility does not manage medications or P&I monies.

LPA reviewed staff and client files. All files were all found to be well organized, thorough and contained the required documentation. Staff files were all found to have current First Aid and CPR certification. Administrator's Certificate for Willie Wei Yang (7032604740) was current with an expiration date of 10/16/2025. Administrator Certificate for Agnes Dizon (6026680735) was current with an expiration date of 06/24/2025. Facility's fire extinguishers were last inspected October 2023. Facility's last emergency/disaster drill was conducted August 2024. Facility's smoke and carbon monoxide detectors were tested and operational.

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CAREPLUS
FACILITY NUMBER: 216803350
VISIT DATE: 08/21/2024
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Continued from LIC809

LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Updated Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance

Documents to be submitted to Community Care Licensing (CCL) by due date of 09/21/2024.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Program Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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