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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700312
Report Date: 02/09/2022
Date Signed: 02/09/2022 11:59:01 AM

Document Has Been Signed on 02/09/2022 11:59 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:PERSON CENTERED SERVICES, INC. #1FACILITY NUMBER:
392700312
ADMINISTRATOR:MOORE, LAURAFACILITY TYPE:
775
ADDRESS:722 W MARCH LNTELEPHONE:
(209) 466-2448
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 255CENSUS: 88DATE:
02/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Laura MooreTIME COMPLETED:
12:05 PM
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On 2-9-22 at 9:58am, Licensing Program Analyst,(LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with program director Laura Moore and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the entry way area, classrooms, common areas, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a 255 capacity adult day program with a current census of 88. Facility has 10 classrooms total. Currently only 3-4 clients utilize each classroom per signage observed. Day program is currently utilizing distance learning as an alternative for participation. Additionally there are activities rooms for client use. LPA also conducted the infection control domain tool. LPA was screened for COVID precautions upon entry. LPA screened facility for COVID cases. No active COVID within facility today. Administrator stated 2 staff are out with positive COVID-19 at this time.
The facility has an approved COVID Mitigation plan LIC 808 form in place. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 112.1*F in the bathrooms and room temperature reads 72*F throughout. Resident classrooms were sanitary and had the required furniture and furnishings. {Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
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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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: PERSON CENTERED SERVICES, INC. #1
FACILITY NUMBER: 392700312
VISIT DATE: 02/09/2022
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The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 6/7/2021. LPA requested the following updated documents: LIC 309 and LIC 308.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Laura Moore and a report was given to Laura.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC809 (FAS) - (06/04)
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