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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804095
Report Date: 10/24/2023
Date Signed: 10/24/2023 03:05:17 PM

Document Has Been Signed on 10/24/2023 03:05 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:PROGRESS FOUNDATION - GRAND AVENUEFACILITY NUMBER:
216804095
ADMINISTRATOR:HERNANDEZ, ELIZABETHFACILITY TYPE:
772
ADDRESS:920 GRAND AVENUETELEPHONE:
(707) 257-9704
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 16CENSUS: 13DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Program Director, Riley ReckTIME COMPLETED:
01:30 PM
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At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1-Year Visit and met with Program Director, Riley Reck. Facility is a Social Rehabilitation Program that provides care and assistance for Adults with Mental Health. Facility has an approved fire clearance and capacity for 16 Ambulatory clients. Upon arrival, LPA was informed that there were 13 clients in care, and 6 staff members on-site.

At approximately 10:00AM, LPA reviewed the facility's staff roster with Program Director. During review, LPA discovered that Staff Member 1 (S1) was fingerprint cleared, but not associated to the facility as required. LPA contacted the Regional Office and confirmed the fingerprint clearance and association status of S1. Facility associated S1 during LPA's visit.

**Program Director understands that a Civil Penalty is not being issued today for S1 because they were associated during LPA's visit.**

At approximately 10:30AM, LPA conducted a walk-though of the facility with Program Director. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility is a one story building with 8 bedrooms, 4 1/2 bathrooms, common areas and staff offices. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. During walk through, LPA observed 2 of 7 sinks were out of compliance with Title 22 Regulations measuring at 122.3F and 121.2F (Technical Violation issued, See LIC9102, Regulation 81088(e)(1)). Per conversation with Program Director, all clients are independent of their Activities of Daily Living (ADLs) and do not have diagnoses of dementia.
LPA observed Client 1 (C1) using a cane while at the facility. Per their physician's report, they have an ambulatory status. LPA informed Program Director that if C1 becomes non-ambulatory and needs an walking device such as a wheelchair or a walker, then an updated Physician's Report will be needed, as well as an updated Fire Clearance and sketch.

Facility has three fire extinguishers which were last inspected April 2022. Facility immediately contacted a vendor to inspect the extinguishers so they are updated appropriately (This deficiency has been cited, see LIC-809D, Regulation 81020(a)(1)).
Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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: PROGRESS FOUNDATION - GRAND AVENUE
FACILITY NUMBER: 216804095
VISIT DATE: 10/24/2023
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Continued from LIC809C

LPA reviewed staff files. Staff files had current First Aid and CPR certification.

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

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), LIC9102 (Technical Advisory/Violation), LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Program Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2023 03:05 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 10/24/2023 at 02:34 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: PROGRESS FOUNDATION - GRAND AVENUE
FACILITY NUMBER: 216804095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81020(a)(1)
81020 Fire Clearance
(a) A social rehabilitation facility shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
(1) The request for fire clearance shall be made through and maintained by the licensing agency.


This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement was not met as evidenced by: Based on observations made, the Licensee did not comply with the section cited above. Licensee did not ensure that 3 of 3 fire extinguishers were serviced or inspected annually as required. Facility contacted vendor and scheduled inspection for fire extinguishers during visit. This poses an immediate health and safety risk to clients in care.
POC Due Date: 10/25/2023
Plan of Correction
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Licensee contacted vendor company to have the fire extinguishers serviced during LPA's visit. Licensee to submit a copy of invoice/receipt and pictures of newly dated tags to Department by POC date of 11/03/2023.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
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