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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803659
Report Date: 03/30/2023
Date Signed: 03/30/2023 04:28:50 PM

Document Has Been Signed on 03/30/2023 04:28 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:AUTISTRY STUDIOSFACILITY NUMBER:
216803659
ADMINISTRATOR:LAWSON, JANET KFACILITY TYPE:
775
ADDRESS:448 DU BOIS STTELEPHONE:
(415) 454-1037
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 30CENSUS: 28DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Chief Operating Officer (COO), Daniel Swearingen, Office Manager, Rhoda RobertsonTIME COMPLETED:
04:30 PM
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At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Inspection visit and met with Chief Operating Officer (COO), Daniel Swearingen, Office Manager (OM), Rhoda Robertson, and Clinical Director (CD), Sara Gardner. The facility is an Adult Day program for very high functioning clients/students, and has an approved fire clearance for 30 Ambulatory clients. Upon arrival, LPA was informed that the many of the Day Program clients were out of the community attending classes at the College of Marin.

At approximately 10:00AM, LPA conducted a walk through of the facility with the COO and OM. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has three activity rooms, a kitchen, a large work shop, a supply room for toxins and art supplies, and office spaces. Per conversation with the COO, clients have access to the three activity rooms and the kitchen. Clients do not enter the work shop or supply room without staff supervision. The COO also stated that clients do not enter staff office spaces.
During the walk through, LPA observed two bottles of Pepto Bismol located in the client accessible refrigerator. Per conversation with the COO and OM, the facility does not administer medications for the clients. All clients administer their own medications without assistance from facility staff. LPA observed the COO and OM immediately move the medication bottles to an inaccessible refrigerator located in a staff office space.
Facility has five fire extinguishers which were last inspected November 2022. Facility has a hard wired fire alarm and sprinkler system that is directly connected to the local Fire Department. Facility's three Carbon monoxide detectors were tested and operational. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility does not provide transportation to or from Day Program.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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: AUTISTRY STUDIOS
FACILITY NUMBER: 216803659
VISIT DATE: 03/30/2023
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Continued from LIC809

The facility's last fire and evacuation drill was conducted March 2023. Per conversation with OM, LPA was informed of the following: P&I Monies are not handled by the facility program. All clients handle their own monetary funds. All clients handle their own hygiene and dietary needs independently, without assistance from facility staff.

At approximately 12:35PM, LPA reviewed facility documents, client files and staff files. LPA conducted a sample review of 5 client files and 5 staff files. Client files were all found to be well organized, thorough and contained the required documentation. Staff files were all found to have First Aid and CPR certification.

LPA requested the following documents to update facility file:
  • Administrative Organization (LIC 309)
  • Affidavit regarding Client/Resident Cash Resources (LIC 400)
  • Control of Property
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Facility Sketch
  • Updated Personnel Report (LIC 500)
  • Surety Bond (LIC 402)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance

Documents to be submitted to Community Care Licensing (CCL) by due date of 4/30/2023.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Clinical Director and Office Manager. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC809 (FAS) - (06/04)
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