216803823-8-31-2023-21-AS-CFES-CV8RUU-20230831132032

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803823
Report Date: 08/31/2023
Date Signed: 08/31/2023 01:20:39 PM

Document Has Been Signed on 08/31/2023 01:20 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 SERVICES		FACILITY NUMBER:	216803823
ADMINISTRATOR:	LUCERO, MARIBETH		FACILITY TYPE:	775
ADDRESS:	70 SAN PABLO AVE		TELEPHONE:	(415) 785-3996
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY: 30		CENSUS: 15	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Staff Member, Jairo Guillen-Vasquez, and Administrator, Maribeth Lucero		TIME COMPLETED:	01:30 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	At approximately 9:30AM, Licensing Program Analyst (LPA) Felias, arrived unannounced to conduct a Required - 1 Year Visit, and met with Staff Member/Supervisor, Jairo Guillen-Vasquez. Facility is an Adult Day Program that provides activities to Individuals with Disabilities. Facility has an approved fire clearance and capacity for 30 Non-Ambulatory Clients. Administrator, Maribeth Lucero, arrived during visit at approximately 10:25AM. Upon arrival, LPA was informed that the Day Program has 15 clients that attend daily but that there were currently 12 Clients attending the program with 8 staff members on-site. At approximately 9:45AM, LPA reviewed the facility staff roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:50AM, LPA conducted a walk-through with Supervisor. LPA observed the following: Facility has a multipurpose area, three activity rooms, laundry area, kitchen, bathrooms, a nurse's room and a staff office. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. During walk through, LPA observed that all sinks in the facility were out of Title 22 Regulations with temperatures reading 126.1F, 126.3F, 126.5F, and 127.0F. Per Title 22 Regulations, hot water temperatures need to be within 105 to 120 degrees Fahrenheit (This deficiency has been cited, see LIC-809D, Regulation 82088(e)(1)). LPA was informed that the facility recently had their water heater regulator inspected and replaced. LPA observed Supervisor lower the water heater temperature during visit. Facility has a mitigation 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 client use. Per conversation with Supervisor, clients bring their own lunches and snacks. Client's Responsible Parties ensure that the client's meals met their dietary needs when attending Day Program. Facility's fire extinguishers were last inspected December 2022. Facility has a hard wired fire alarm and sprinkler system that is directly connected to the local Fire Department. Facility's smoke detectors were last inspected March 2023. Facility's sprinkler system was last tested January 2023. Facility's last fire drill was conducted April 2023. Facility's carbon monoxide detectors were tested and operational. Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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: 08/31/2023

NARRATIVE

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At approximately 10:45AM, LPA reviewed 6 Staff files and 6 Client files. Client and Staff 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. During Client file review, LPA observed that two clients require the use of a gastronomy tube (G-Tube). Facility provided LPA with proof of G-tube Training, and Client Health Care Plans. At approximately 12:35PM, LPA reviewed Client medication records and found that they were centrally stored and secure.

LPA is requesting the following documents to update facility file:

Control of Property
Designation of Facility Responsibility (LIC308)
Emergency Disaster Plan (LIC610D)
Updated Personnel Report (LIC500)
Register of Clients/Residents (LIC9020)

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

Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/31/2023 01:20 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 08/31/2023 at 12:59 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: LIGAYA DAY SERVICES	FACILITY NUMBER: 216803823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(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
1 2 3 4	Based on LPA observation, the Licensee did not comply with the section cited above in 4 of 4 sinks. LPA observed that facility's water temperatures measured at 126.1F, 126.3F, 126.5F and 127.0F. This poses a potential health and safety risk to clients in care.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	Licensee to submit a water temperature log, documenting the facility's water temperature for 7 days. Water temperature to be taken once in the morning and once in the afternoon. Temperature Log to include the following: date, time, sink location, and temperature. Log to be submitted to the Department for review and approval by POC due date of Monday, 09/11/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Kimberley Mota

LICENSING EVALUATOR NAME:

Caitlynn Felias

LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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