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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317185
Report Date: 03/14/2022
Date Signed: 03/22/2022 02:42:21 PM

Document Has Been Signed on 03/22/2022 02:42 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, 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: 10DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
01:00 PM
NARRATIVE
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Unannounced annual visit made out to this day program on 03/14/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by staff member Jaime Palacios who was briefly interviewed. This LPA requested that Mr. Palacios go ahead and contact the facility program Manager, Frankie Orona, to inform her that CCL was present at this time. Mrs. Orona arrived shortly thereafter to this day program while this LPA was conducted the physical plant walk through.
Current census was 10 clients. This day program is set to maintain a 3:1 client to staff ratio at all times.
Tour of this facility was conducted. Kitchen area was toured. It was learned that this area was used mainly to heat up client meals at this time. This day program is still transitioning back to handling more clients on a full time basis.
Day program restrooms (2) were toured. Hot water temperatures were taken and measured to make sure that the hot water being dispensed was within the allowed range of 105-120 degrees.
Activities supplies were reviewed and observed to be sufficient and able to meet the needs of the clients at this time.
Fire extinguishers, located throughout this day program, were observed to have been annually inspected on 07/01/2021 by Butch Fire Equipment and in compliance at this time.
It was observed that this day program consisted of a main room that was partitioned into two separate spaces that were used at this time.
A tour of the exterior grounds was conducted. Areas where clients were dropped off and picked up were toured. A review of the facility exits was conducted. It was learned that all exits were not alarmed nor were any of them used for emergency exit purposes only.
The following forms and documents were requested by this LPA to be updated and submitted into CCL:

LIC 308, LIC 400, LIC 500, and LIC 610

There were no deficiencies observed or cited during today's annual visit. Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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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