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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700054
Report Date: 03/09/2022
Date Signed: 03/09/2022 01:28:03 PM

Document Has Been Signed on 03/09/2022 01:28 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ADULT VOCATIONAL SERVICES INCFACILITY NUMBER:
312700054
ADMINISTRATOR:SUH, SEANFACILITY TYPE:
775
ADDRESS:3845 ATHERTON RD #7TELEPHONE:
(916) 204-5726
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 30CENSUS: 30DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Michael Palmer, Program DirectorTIME COMPLETED:
02:08 PM
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On March 9, 2022, at 12:45pm, Licensing Program Analyst (LPA) De Anna Williams-Lyons made an unannounced visit to conduct facilities required annual inspection. LPA Lyons met with Michael Palmer, Program Director and explained the purpose of the visit.

Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and a N-95 mask was worn for Personal Protective Equipment (PPE).

Michael and LPA completed the infectious control questionnaire with no issues.

LPA observed the following:
Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguishers fully charged. Hot water temperature measured 105 degrees F. Common areas were clean and in good repair. Bathrooms and activity rooms were in good repair and had required furniture and lighting. There are no bodies of water on the premises.

As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6.

The Program Director shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file in our office. Program Director shall submit the listed documents to Licensing no later than April 9, 2022.

Exit interview conducted and a copy of this report given to Michael.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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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