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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803823
Report Date: 09/23/2024
Date Signed: 09/23/2024 01:24:41 PM

Document Has Been Signed on 09/23/2024 01:24 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:LIGAYA DAY SERVICESFACILITY NUMBER:
216803823
ADMINISTRATOR/
DIRECTOR:		LUCERO, MARIBETHFACILITY TYPE:
775
ADDRESS:70 SAN PABLO AVETELEPHONE:
(415) 785-3996
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 30CENSUS: 26DATE:
09/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Staff Member/Supervisor, Jairo Guillen-VasquezTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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At approximately 9:05AM, Licensing Program Analyst (LPA) Felias, arrived unannounced to conduct a Required - 1 Year Visit, and met with Staff Member/Supervisor, Jairo Guillen-Vasquez. Administrator, Maribeth Lucero, was available by telephone. Facility is an Adult Day Program that provides activities for Adults with Disabilities. Facility has an approved fire clearance and capacity for 30 Non-Ambulatory Clients. Upon arrival, LPA was informed that were 26 Clients attending the program and 18 staff members on-site.

At approximately 9:20AM, 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 9:25AM, LPA conducted a walk-through with Staff Member. LPA observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility is a one story building with a multipurpose area, three activity rooms, laundry area, kitchen, 2 bathrooms, a nurse's room and a staff office. Facility had emergency lighting. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. 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 Staff Member, clients bring their own lunches and snacks. Client's Responsible Parties ensure that client meals meet their dietary needs when attending Day Program. Facility does not manage P&I monies for clients.

Facility's last emergency/disaster drill was conducted August 2024. Facility's fire extinguishers were last inspected December 2023. Facility has a hard wired fire alarm and sprinkler system that is directly connected to the local Fire Department. Facility's smoke detectors and sprinkler system were last tested December 2023. Facility's carbon monoxide detectors were tested and operational.

At approximately 10:15AM, LPA reviewed staff and client files, and client medication. 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. During medication review, LPA was informed that all clients that receive medication management at Day Program bring their medications with them and take them back home when Program has ended.

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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 2
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: LIGAYA DAY SERVICES
FACILITY NUMBER: 216803823
VISIT DATE: 09/23/2024
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Continued from LIC809

Facility maintains a Medication Authorization Record (MAR) of medications being administered which was observed to be appropriately maintained.

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 10/23/2024.

No Deficiencies Cited during visit.

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

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC809 (FAS) - (06/04)
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