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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317363
Report Date: 09/08/2023
Date Signed: 09/08/2023 01:50:09 PM

Document Has Been Signed on 09/08/2023 01:50 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: 61DATE:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lupe LopezTIME COMPLETED:
02:00 PM
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On 9/8/23 at approximately 10:30 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required annual inspection. LPA Jensen met with Program Assistant Lupe Lopez and explained the purpose of today's visit.

Physical Plant and Grounds: The facility is licensed for 70 non-ambulatory clients. The current census is 61 however the majority of clients are participating virtually. There are approximately 27 or less clients on site on any given day at this time. On this day there were 25 clients in Program on site. LPA Jensen toured the grounds and observed all paths to be clear of obstruction. LPA Jensen toured the interior of the facility and observed it to be sanitary and free of odor. The main activity rooms, ancillary activity rooms, computer lab, bathrooms, kitchen and offices were toured. Food is not prepared on site, clients bring their own lunch. The kitchen is used eating and cooking classes. LPA Jensen did not observe any knives or toxins, or cleaning supplies in the kitchen. The water temperature in the kitchen was measured at 118 degrees Fahrenheit which is within the required range 105-120 degrees Fahrenheit. The facility had adequate lighting and furnishings throughout. The facility maintains a variety of activities for client engagement. LPA Jensen observed lunch service and a bingo game during the course of the visit. The thermostat was set a 71 degrees Fahrenheit.

Safety Measures: LPA Jensen checked the carbon monoxide detector and smoke detector and determined them to be in good working order. The fire extinguisher was last serviced on September of 2023 and is in compliance. The facility conducts fire drills semi-annually. There is a first aid kit on site that was observed to be complete and in compliance. All toxins and cleaning supplies were observed to be stored in a locked storage closet.

Record Review: LPA Jensen reviewed 5 of 25 client files and found them to be complete. LPA Jensen reviewed 3 staff files. The emergency disaster plan was reviewed and determined to be in compliance.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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 4
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: 09/08/2023
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Continued from LIC 809...

Record Review: LPA Jensen conducted a random medication audit and observed the Medication Administration Record (MAR) to be complete. Medications are stored on a locked cart and kept in a locked room. LPA Jensen received an updated LIC 309. A current LIC 500 and liability insurance certificate was obtained.

Interviews: LPA Jensen interviewed 2 staff members. No clients were interviewed as all were very engaged in activities.

Technical assistance was provided for infection control and Administrator Qualifications and Duties.

The inspection tool was utilized during the course of this visit. The facility was determined to be in substantial compliance and no deficiencies are being cited.

An exit interview was conducted with Lupe Lopez and a copy of this report and appeal rights were given.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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