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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701382
Report Date: 12/30/2024
Date Signed: 01/25/2025 08:16:20 PM

Document Has Been Signed on 01/25/2025 08:16 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WIDE HORIZONS INCFACILITY NUMBER:
392701382
ADMINISTRATOR/
DIRECTOR:		STELMACK, MONICAFACILITY TYPE:
775
ADDRESS:1032 W YOSEMITE AVETELEPHONE:
(209) 629-8968
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 15CENSUS: 5DATE:
12/30/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Carol DavisTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Unannounced Post Licensing visit made out to this day program on 01/24/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility interim designated Administrator, Carol Davis, who briefly interviewed at this time.
Current census was 5 clients, of which, only (1) client was present at this time.
This day program was currently seeking vendorization through Valley Mountain Regional Center as well. It was learned that this day program was expected to maintain a 5:1 ratio for clients to staff at all times according to its program design.
Tour of this day program was conducted.
It was observed that there was a classroom unit that was present and utilized at this time. A partition was used to created two separate classrooms at this time.
All areas designated as classrooms, activity areas, and common areas for client use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the clients at this time.
Office rooms and other areas intended for client use were toured.
A review of the day program restrooms was conducted.
Hot water temperatures were taken to make sure that the hot water being dispensed was within the allowed range of 105-120 degrees at all times.
Fire extinguishers, placed throughout this day program, were observed to have been annually inspected on 10/10/2024 by the local fire extinguisher company, Nor Cal and Company, and in compliance at this time.
Kitchen area was toured.
The use of a microwave was the only method utilized to heat and warm up the food for the clients, if necessary, at this time.
There wasn't an oven or stove unit present at this time.
Facility food storage unit, refrigerator, was reviewed and observed to be functional and in good repair at this time.
Storage area for chemicals and cleaning supplies was observed to be locked and made inaccessible to the
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: WIDE HORIZONS INC
FACILITY NUMBER: 392701382
VISIT DATE: 12/30/2024
NARRATIVE
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clients at this time.
Exterior grounds of this day program were toured at the rear area of this day program.
Rear gate was observed to be functional and in good repair at this time.

A file review was conducted for the day program client files (5) at this time. These details were noted on the following LIC 858.

A file review was conducted for the day program staff (3) files at this time. These details were noted on the following LIC 859.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was left with the facility designated representative at this time.

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

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2025 08:16 PM - It Cannot Be Edited


Created By: Charlie Yang On 01/24/2025 at 12:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WIDE HORIZONS INC
FACILITY NUMBER: 392701382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82068.2(f)(1)(B)
Needs and Services Plan
(f) The completed Needs and Services Plan shall include: (1) The client's desires and background and formal supports, obtained from the client's family or his/her authorized representative, if any, regarding the following: (B) A written medical assessment including primary physician, health problems and medical history, prescribed medications and their strength, quantity, frequency required and purpose as specified in Section 82069(b)(3).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that [3] out of [5] facility client records were missing the required medical assessment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/25/2025
Plan of Correction
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The facility designated representative stated that a review of all day program clients' records will conducted and updated to contain the required medical assessment addressing ambulatory status and any medical issues, including TB clearance, at all times. A statement of correction, along with copies of the updated medical assessments for the day program clients, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/25/2025 08:16 PM - It Cannot Be Edited


Created By: Charlie Yang On 01/24/2025 at 12:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WIDE HORIZONS INC
FACILITY NUMBER: 392701382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. A separate, complete, and current record shall be maintained at the program site for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review)], the licensee did not comply with the section cited above in [5] out of [5] day program client records were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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The facility designated representative stated that a review of all day program clients' records will conducted and updated to contain all of the required forms and documents at all times. A statement of correction, along with copies of the updated forms and documents for the day program clients, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
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