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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202077
Report Date: 10/07/2021
Date Signed: 10/08/2021 01:31:56 PM

Document Has Been Signed on 10/08/2021 01:31 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,
, CA
FACILITY NAME:SVS MARINA ADULT DAY PROGRAMFACILITY NUMBER:
275202077
ADMINISTRATOR:RITA FAATUAIFACILITY TYPE:
775
ADDRESS:330 RESERVATION RD. STE. DTELEPHONE:
(831) 582-2961
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY: 60CENSUS: 0DATE:
10/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Rita FaatuaiTIME COMPLETED:
12:55 PM
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Licensing Program Analysts (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Rita Faatuai, Program Director LPA observed no clients on site and the program is offering virtual and community based activities. The facility has 60 clients participating in the program which operates five days a week. 28 of the 60 clients participate in community based outings which are originated from the client's residential site. These outings are staggered for 20 clients Monday, Wednesday and Friday and 8 clients on a Tuesday and Thursday schedule. 3 clients participate in a work program. Community activities to include walking, exercise, music, dance and socialization. The facility provides transportation services. All clients are screened at the time of pick-up.

LPA toured the facility inside and out to include the entry, kitchen, conference room, activity rooms, offices, quiet room and storage room. All fire exit routes were free and clear of obstructions. Toxins, cleaning supplies and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products and hand washing signs were posted. Hand sanitizer available to clients and visitors throughout the facility. LPA observed supply of Personal Protective Equipment (PPE). The facility has a COVID 19 Mitigation Plan in place.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Rita Faatuai, Program Director and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2021
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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