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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005196
Report Date: 09/20/2021
Date Signed: 09/20/2021 04:34:28 PM

Document Has Been Signed on 09/20/2021 04:34 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:APPLIED ABILITIES PROGRAMFACILITY NUMBER:
397005196
ADMINISTRATOR:LYNN HOGUEFACILITY TYPE:
775
ADDRESS:324 E. 11TH STREET., STE. C&DTELEPHONE:
(209) 956-0290
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 60CENSUS: 58DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Deirdre Murchison, Assistant Program Manager,TIME COMPLETED:
02:53 PM
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA was greeted by Deirdre Murchison, Assistant Program Manager, S1. Proper screening was conducted prior to entry. LPA observed documents of screening completed for all consumers and staff.

There are 10 consumers attending program in person.. Due to Covid 19, facility is enrolling clients for in-person in waves. Facility reopened program Sept 13th, 2021. Most of the clients are conducting classes via Zoom and classroom packets are being delivered to 48 consumers for Zoom instruction. LPA observed packets being prepared for consumers.

LPA toured the physical plant including the classrooms, bathrooms, kitchen area and activities area. The kitchen areas had refrigerators and microwaves. Kitchen is closed to consumers at this time. Cleaning supplies were observed to be inaccessible to consumers and dangerous items such as knives are locked away and inaccessible. All client restrooms are maintained with soap and paper towels available for the clients. Hot water temperature was observed to be 105 degrees F. Fire extinguishers were serviced in 9/3/2021 in classroom area and 10/14/20 in Office Area. Smoke detectors and fire alarm systems are installed in the building as well as built in sprinkler system. Carbon monoxide detectors are installed in the building.
The common areas used for consumers were odor free and all clients appeared to be in the appropriate level of care. No medications are being managed by facility at this time.

15 staff records were reviewed. LPA also reviewed 9 client records, all containing accurate documentation needed. Emergency Plan posted and updated on 5/2021.
Nine of 10 consumers vaccinated. Eleven of 15 staff vaccinated. LPA observed 30 days PPE supply.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, NO deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with S1 and a copy of report given via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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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