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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803659
Report Date: 05/22/2024
Date Signed: 05/22/2024 01:00:50 PM

Document Has Been Signed on 05/22/2024 01:00 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AUTISTRY STUDIOSFACILITY NUMBER:
216803659
ADMINISTRATOR/
DIRECTOR:		LAWSON, JANET KFACILITY TYPE:
775
ADDRESS:448 DU BOIS STTELEPHONE:
(415) 454-1037
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 30CENSUS: 6DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Chief Operating Officer (COO), Daniel Swearingen, Office Manager, Rhoda RobertsonTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Chief Operating Officer (COO), Daniel Swearingen, Office Manager (OM), Rhoda Robertson, and Staff Member, Shelby Green. 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 there were currently 6 clients at the program and 4 staff members on-site.

At approximately 9:35AM, 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 9:45AM, LPA conducted a walk through of the facility with the OM. LPA observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has an Infection Control Plan on file. Facility has three activity rooms, a kitchen, a large work shop, a supply room for toxins and art supplies, and office spaces. Clients have access to the three activity rooms and the kitchen. Clients do not enter the work shop or supply room without staff supervision. Clients do not enter staff office spaces. Clients manage their own monetary funds, medications, transportation, and bring their own snacks and lunches to program.

Hot water temperatures for all sinks in facility were observed to be outside of Title 22 regulations of 105 to 120 degrees Fahrenheit, measuring at temperatures of 124.7F to 125.9F. LPA observed that the facility's knives and sharps drawer was open and unlocked during walkthrough. LPA also observed that Comet Bleach, Barkeeper's Friend, and 409 cleaning solution was unlocked and accessible in the facility kitchen and bathroom. Facility staff immediately locked knives drawer and ensured that the cleaning supplies were put away and inaccessible (these deficiencies have been cited, see LIC809D, regulation 82088(e)(1) and regulation 82087(a)(3)). LPA observed that bathroom garbage cans do not have lids (see Technical Advisory, LIC9102, regulation 82088(f)(1). Facility's fire extinguishers were last inspected May 2024. Facility's last emergency/disaster drill was conducted May 2024. Facility's smoke and carbon monoxide detectors were last tested May 2024.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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 5
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: AUTISTRY STUDIOS
FACILITY NUMBER: 216803659
VISIT DATE: 05/22/2024
NARRATIVE
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Continued from LIC809

At approximately 10:35AM, 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 First Aid and CPR certification.

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 06/22/2024.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Office Manager. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/22/2024 01:00 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 05/22/2024 at 12:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AUTISTRY STUDIOS
FACILITY NUMBER: 216803659

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
82087 Buildings and Grounds
(a)The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. Licensee did not ensure that the following were locked and inaccessible to clients: cleaning solutions (Comet Bleach, Barkeeper's Friend, and 409 Cleaning Solution) and the facility's knives/sharps drawer. This poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 05/23/2024
Plan of Correction
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Licensee to submit self certification stating that they will review the above regulation and conduct an in-service training for all staff. In-service training to include the following: Training Topic, Date, Staff Names/Job Title, and staff signatures. Self Certification to be submitted by POC due date of 05/23/2024. Inservice Training to be submitted by POC due date of 06/07/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 05/22/2024 01:00 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 05/22/2024 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AUTISTRY STUDIOS
FACILITY NUMBER: 216803659

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82088(e)(1)
82088 Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care shall deliver hot water. (1)Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above for all sinks in facility. All sinks measured between 124.7F and 125.9F. This poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 06/07/2024
Plan of Correction
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Licensee to submit a water temperature log for 10 days for all sinks in facility. Temperature to be checked twice a day starting 05/23/2024 and ending 06/07/2024. Log to include time when water was checked. Log to be submitted to CCL for review and approval by POC due date 06/07/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
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