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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803252
Report Date: 04/07/2022
Date Signed: 04/07/2022 01:29:46 PM

Document Has Been Signed on 04/07/2022 01:29 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:UNITED CEREBRAL PALSY OF THE NORTH BAYFACILITY NUMBER:
286803252
ADMINISTRATOR:LISENKO, MIKEFACILITY TYPE:
775
ADDRESS:500 TECHNOLOGY WAYTELEPHONE:
(707) 603-0010
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 180CENSUS: 39DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Program Manager, Briana Terrell-BachelorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Willis arrived unannounced to conduct an Annual inspection visit and met with Program Manager, Briana Terrell-Bachelor. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival at the facility, LPA was asked to sign in and fill out a questionnaire with standard Covid-19 screening questions. Temperature was checked and documented. 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 including hand-washing signs in the bathrooms. LPA observed staff were wearing masks. Participants also wear masks while in the facility. During inspection, participants were eating lunch. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Bathrooms had hand washing supplies and hand sanitizing dispensers were observed throughout the facility.

Staff receive training on infection control and proper donning and doffing of Personal Protective Equipment (PPE). Facility has a janitorial company that cleans and disinfects the facility at least twice per day which includes bathrooms and frequently touched surfaces. Staff clean and disinfect areas after use. Facility has at least a 30-day supply of PPE. Staff and participants are screened daily for COVID-19 symptoms and it is logged. Facility is following vaccination the guidance per PIN 22-05.1-ASC.

Fire Extinguishers were last serviced January 2022. Facility is located in a building that has a management company who is responsible for maintenance of the fire system.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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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