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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803823
Report Date: 09/27/2022
Date Signed: 09/27/2022 03:03:43 PM

Document Has Been Signed on 09/27/2022 03:03 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:LIGAYA DAY SERVICESFACILITY NUMBER:
216803823
ADMINISTRATOR:LUCERO, MARIBETHFACILITY TYPE:
775
ADDRESS:70 SAN PABLO AVETELEPHONE:
(415) 785-3996
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 30CENSUS: DATE:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Maribeth LuceroTIME COMPLETED:
03:20 PM
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At approximately 12:15PM, Licensing Program Analyst (LPA) Felias, arrived unannounced to conduct a Required 1 Year Visit, and met with Administrator, Maribeth Lucero. The Inspection Visit is focused on the Infection Control procedures and practices of this facility.

Upon arrival at facility, LPA was informed that the facility is currently not open for clients to attend in-person. All clients are currently attending the day program via Zoom video calls, or by staff going to the client's homes to conduct activities. However, staff members are screened daily and sign into the facility's visitor log.
LPA reviewed sign-in log and observed that staff members are taking their temperatures and answering the symptom questionnaire. Administrator confirmed that staff take a weekly Covid Test and ensure they are negative before conducting activities at client residences.

LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. Observed staff were wearing masks. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

LPA and Administrator discussed the following: Activities, N95-Fit Testing and available resources. Facility is in the process of obtaining Testing for all staff. Facility has a backup plan if facility has a staffing shortage.

All staff have received training on Infection Control. Facility has a cleaning and disinfecting schedule that occurs twice per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for Clients.

Continued on LIC-809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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: LIGAYA DAY SERVICES
FACILITY NUMBER: 216803823
VISIT DATE: 09/27/2022
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Continued from LIC-809

LPA requested the following documents to be submitted to Community Care Licensing (CCL) by Friday, 10/21/2022.
  • Administrative Organization (LIC 309)
  • Affidavit Regarding Client Cash Resources (LIC 400)
  • Copy of Lease/Control of Property
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Surety Bond (LIC 402)
  • Register of Facility Clients/Residents (LIC 9020)


Fire extinguishers were last serviced January 2022. Fire alarm system is directly connected to the San Rafael Fire Department. Carbon monoxide detectors were tested and operational.

Exit interview conducted. Copy of report, LIC 9102 (Technical Violation and Technical Assistance), discussed and provided to Administrator. Signature on form confirms receipt of documents.

No Deficiencies cited during visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC809 (FAS) - (06/04)
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