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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005816
Report Date: 10/03/2024
Date Signed: 10/03/2024 12:15:34 PM

Document Has Been Signed on 10/03/2024 12:15 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:NO LIMITS LEARNING CENTERFACILITY NUMBER:
306005816
ADMINISTRATOR/
DIRECTOR:		ENGLISH, COURTNIFACILITY TYPE:
775
ADDRESS:925 W. LAMBERT RD. UNIT CTELEPHONE:
(714) 674-0368
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY: 150CENSUS: 95DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Maryalice Garcia, Director of Operations and Stacie Knepp, Program AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #3 at 8am. During today’s visit, LPA met with Maryalice Garcia, Director of Operations and Stacie Knepp, Program Administrator.

The facility is an Adult Day Program housed in a two story industrial building with an approved fire clearance of one hundred fifty ambulatory clients. The first floor has five classrooms, an art studio, a sensory room and multipurpose room; as well as men and women bathrooms. There is a large health and fitness area with machines, a partitioned art classroom, lunch tables, arcade area and indoor basketball court. The second floor has one classroom and houses the administrative staff. The facility currently has a census of ninety-five clients in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing hot water temperature in bathrooms and testing auditory devices on all exits. The hot water temperature measured between 105.2 and 105.4 degrees Fahrenheit and all smoke detectors were operational and are tested annually by the property management. LPA observed security cameras throughout the perimeter of the facility that are visual only. There are several fire extinguishers and First Aid Kits in all classrooms with the required elements which include a First Aid Manual. The fire extinguishers are charged and were serviced on November 15, 2023. The facility’s last fire drill was conducted on June 26, 2024.

LPA noted lockers are provided for each client and refrigerators and freezer are secured for the Snack Shack. Clients bring their own lunches and snacks but a Snack Shack is available during break times for clients to practice handling money and life skills. All cleaning supplies and emergency supplies were secured. LPA observed clients in their classrooms with instructors. Clients are responsible for their own medications and are not handled by the Day Program. (Continued on LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NO LIMITS LEARNING CENTER
FACILITY NUMBER: 306005816
VISIT DATE: 10/03/2024
NARRATIVE
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(Continued from LIC 809)

Client files are secured upstairs in the conference room. LPA reviewed four of four staff training and fingerprint records. LPA reviewed four of four client records. Client records did not have Admissions Agreements on file since originals were given to the family members; only a signed acknowledgment was on file regarding Admissions Agreements. Three of four client records did not have a Medical Assessment on file. LPA interviewed alert clients regarding their quality of care and spoke to staff present regarding services provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Maryalice Garcia, Director of Operations and Stacie Knepp, Program Administrator and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/03/2024 12:15 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 10/03/2024 at 11:53 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NO LIMITS LEARNING CENTER
FACILITY NUMBER: 306005816

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(a)
Admission Agreements
(a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in three of four client records which poses a potential health, safety or personal rights risk to persons in care. Client files had signed acknowledgements of receiving Admissions Agreements only.
POC Due Date: 10/24/2024
Plan of Correction
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Facility will be updating all client records and printing Admissions Agreements for each client record with all the required services to comply with Title 22 Regulations. Facility will email LPA the updated Admissions Agreements, with signatures, for client files reviewed during the annual visit
Type B
Section Cited
CCR
82069(a)(1)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan. (1) The assessment shall be performed by a licensed physician or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA review of client records the licensee did not comply with the section cited above in three of four client records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2024
Plan of Correction
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Facility will send LIC 602 Physician's Report paperwork to all families to ensure all clients have a medical assessment on file. Upon completion, facility will email LPA with Medical Assessments for client files reviewed during the annual visit.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/03/2024 12:15 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 10/03/2024 at 11:53 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NO LIMITS LEARNING CENTER
FACILITY NUMBER: 306005816

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(b)(1)
Client Medical Assessments
(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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