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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317363
Report Date: 09/20/2022
Date Signed: 09/20/2022 12:32:11 PM

Document Has Been Signed on 09/20/2022 12:32 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 JOAQUINFACILITY NUMBER:
390317363
ADMINISTRATOR:RAY CALLFACILITY TYPE:
775
ADDRESS:333 W. BENJAMIN HOLT DRIVETELEPHONE:
(209) 956-0290
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 70CENSUS: 10DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Program Manager Shirly Ridoloso ChanthavongTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a one year required/annual inspection. LPA met with Program Manager Shirly Ridoloso Chanthavong and explained the reason for the visit. Census 10.

LPA Lund and Program Manager Shirly Ridoloso Chanthavong walked the facility that is licensed to serve a total capacity of 70 clients. The facility is a Day Program. 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.

The physical plant was toured inside and outside to ensure the safety of the clients. LPA observed first aid kits was found in compliance containing at least the following: a current approved edition of a first aid kit was at the facility. LPA observed fire extinguisher last inspected on 5/17/2022, smoke and carbon monoxide detectors, central heating and air in the facility. Last fire drill was conducted on 8/12/2022.


Per the California Code of Regulations, Title 22, Division 6, no deficiencies observed or cited. Exit interview held Program Manager Shirly Ridoloso Chanthavong, copy of report given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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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