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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002220
Report Date: 09/08/2021
Date Signed: 09/08/2021 10:39:38 AM

Document Has Been Signed on 09/08/2021 10:39 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 #2FACILITY NUMBER:
397002220
ADMINISTRATOR:ANN MARRIOTTFACILITY TYPE:
775
ADDRESS:4155 N. EL DORADO STREETTELEPHONE:
(209) 466-2448
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 135CENSUS: 117DATE:
09/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Ann MarriottTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required – 1 Year inspection on 9/8/2021 at 9:10am. LPA met with Designated Staff one (S1) and stated the purpose of today’s visit. LPA contacted Ann Marriott prior to today's visit for COVID screening. LPA was allowed entry into the facility, screened for COVID precautions, and was accompanied by S1 throughout the inspection tour of the facility that is licensed to serve a total capacity of 135 clients. Today's census is 117 enrolled in remote alternative services of which 16 are in using person services. LPA observed six of six staff associated and cleared in Licensing Information System.

The facility is a Day Program that has resumed in person services July 2021 and have been providing alternative services to clients via Zoom and other programs since March 2020. The day program has two class rooms with private restrooms set up to meet clients staffing level needs and abilities. LPA observed tables and chairs to serve the capacity and promote social distancing and disinfectant available for use. LPA observed chemicals and scissors unlocked secured in an area clients do not have access to. LPA observed all areas to be clean and in good repair. The facility deep cleans and disinfects surfaces in the morning, in-between pods of clients and at the end of the day.

The physical plant was toured inside and outside to ensure the safety of the clients. The temperature inside the facility was measured between at 72*F and 80*F which is within the required range of 68*F and 85*F. The hot water was measured at 106* F and 111*F which is within regulatory range of 105*F and 120*F. LPA observed first aid kits in each class room and the main office was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed a pull alarm system, fire extinguishers inspected on 6/4/2021, smoke and carbon monoxide detectors, central heating and air in the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2021
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: PERSON CENTERED SERVICES, INC #2
FACILITY NUMBER: 397002220
VISIT DATE: 09/08/2021
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Upon a file review the following items were discussed to be submitted with any changes to LPA by 9/30/2021:

Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Qualifications of Administrator/Facility Manager
Emergency Disaster Plan LIC610
First aid/CPR certificates

Per the California Code of Regulations, Title 22, no deficiencies observed or cited. Exit interview held with S1 and Ann Marriott, and copy of report provided. A signature on these forms acknowledges receipt of these forms.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC809 (FAS) - (06/04)
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