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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317185
Report Date: 11/12/2021
Date Signed: 11/13/2021 09:25:55 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/13/2021 09:25 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:UNITED CEREBRAL PALSY OF SAN JOAQUIN CO.FACILITY NUMBER:
390317185
ADMINISTRATOR:CORINNE FIELDERFACILITY TYPE:
775
ADDRESS:134 PACIFIC ROADTELEPHONE:
(209) 239-3066
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 40CENSUS: 4DATE:
11/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:F. OronaTIME COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced required/annual visit on today's date.

LPA was met by the Program Manager, Francisca Orona who conducted todays visit. LPA Johnson toured the facilities physical plant.

LPA observed that all the clients have access to personal space and bring their own lunch. The facility does hold a cooking class for the clients. LPA observed clients have access to water when requested. Hot water temperature measured at 119*F which is within the required range of 105-120*F.

The facility provides activities for the clients. The first aide was checked and has the required tweezers, thermometer and scissors. Medication is given to two clients. Medications were locked and secured. Disinfectants were locked and inaccessible to clients. The fire extinguishers were checked and are up to date on service.

10 Client and 5 staff files were reviewed on today's visit and are complete.

Per the California Code of Regulations, Title 22, no deficiencies observed or cited.

Exit interview held, copy of report given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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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