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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317185
Report Date: 03/06/2023
Date Signed: 03/07/2023 10:36:08 AM

Document Has Been Signed on 03/07/2023 10:36 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
SACRAMENTO AC/SC, 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: 25DATE:
03/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jaime PalaciosTIME COMPLETED:
01:30 PM
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Unannounced annual visit conducted on 03/06/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by facility personnel, Jaime Palacios (Instructor), who was requested by this LPA to go ahead and notify the facility designated Administrator, Frankie Orona, that CCL was present at this time. It was learned that Mrs. Orona was unable to be present at this time since she was covering as the facility designated Administrator for their Stockton branch.
All forms and documents were going to be reviewed and signed by facility personnel Jaime Palacios.
Current census was 25 clients.
It was learned that this day program was vendorized through Valley Mountain Regional Center and should maintain, at all times, a 3:1 client to staff ratio.
Tour of this day program was conducted.
It was observed by this LPA that this day program consisted of three areas that were zoned and partitioned off for unique purposes. Each zone was assigned to facility staff and facility clients alike.
Kitchen area was toured. This area was considered to be Zone 2. All gatherings for the clients was set up in this area before they departed for the day into the community.
Cabinets and drawers were reviewed. Bleach, sharps, and all cleaning supplies were observed to be locked and made inaccessible to the clients at this time. It was learned that cooking skills were taught to the clients in care as well in this zone.
Client restrooms were toured. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees at all times.
Supply closet housing all of this facility's cleaners, bleach, and all other supplies necessary to run and maintain this program was observed to be locked and made inaccessible to the clients at this time.
A tour of Zone 1 was conducted. Furniture and furnishings were observed to be in good repair and able to meet the needs of the clients at this time.
A tour of Zone 3 was conducted. Furniture and furnishings were observed to be in good repair and able to meet the needs of the clients at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: UNITED CEREBRAL PALSY OF SAN JOAQUIN CO.
FACILITY NUMBER: 390317185
VISIT DATE: 03/06/2023
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First aid kit was observed to be present and contained all of the required components at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 04/30/2022 by the local fire extinguisher company, Butch Young Fire Equipment, and in compliance at this time.
A tour of the facility exterior grounds was conducted. This facility does not have a surrounding perimeter fence or side gate exits.
A review of (5) client files was conducted.
A review of (5) facility staff files was conducted.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC809 (FAS) - (06/04)
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