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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317363
Report Date: 09/24/2021
Date Signed: 09/24/2021 11:52:35 AM

Document Has Been Signed on 09/24/2021 11:52 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 JOAQUINFACILITY NUMBER:
390317363
ADMINISTRATOR:RAY CALLFACILITY TYPE:
775
ADDRESS:333 W. BENJAMIN HOLT DRIVETELEPHONE:
(209) 956-0290
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 70CENSUS: 62DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Tonish MixonTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required – 1 Year inspection on 9/24/2021 at 10:25am. LPA met with Designee Jana Vann and stated the purpose of today’s visit and was allowed entry into the facility and was accompanied by Jana throughout the inspection tour of the facility that is licensed to serve a total capacity of 70 clients. Today's census is 62 enrolled in remote alternative services and 1 client coming on site. LPA observed six of six staff present associated with criminal record clearance in Licensing Information System. Program Director arrived on site during the inspection.

The facility is a Day Program that has not been operating in person services since March 2020 but have been providing remote services to clients via Zoom, other video programs and sending packets. The day program has with a large central open area for services, two restrooms, staff office, isolation room, and kitchen with staff break room set up to meet clients needs and abilities. LPA observed tables and chairs to serve the capacity of the day program and promote social distancing. LPA observed staff conducting zoom with clients and 1 in person service.

The day program is looking at new reopening requirements and following State guidelines prior to increasing on site clients for in person services. The physical plant was toured inside and outside to ensure the safety of the clients. The kitchen faucet was observed broken not regulating water temperature. The temperature inside the facility was measured at 75*F which is within the required range of 68*F and 85*F. The hot water was measured at 108*F in the restroom which is within regulatory range of 105*F and 120*F. LPA observed first aid kits was found in compliance containing at least the following: a current approved edition of a first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed fire extinguisher last inspected on 6/4/2021, smoke and carbon monoxide detectors, central heating and air in the facility. Last fire drill was conducted on 9/3/2021.
Continued from 809.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
FACILITY NUMBER: 390317363
VISIT DATE: 09/24/2021
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The facility has an approved mitigation plan on file with the Department.

Upon a file review the following items were discussed to be submitted with any changes annually to LPA by 10/15/2021.

Administrative Organization LIC309
In-service Training Program
Transportation Procedures
First aid/CPR certificates for all staff
Personnel Report LIC500
Plan of Operations

Per the California Code of Regulations, Title 22, Division 6, no deficiencies observed or cited. Exit interview held, copy of report given. A signature on this form acknowledges receipt of these documents.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC809 (FAS) - (06/04)
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