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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005196
Report Date: 10/07/2022
Date Signed: 10/10/2022 02:54:44 PM

Document Has Been Signed on 10/10/2022 02:54 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: 0DATE:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Deirdre MurchisonTIME COMPLETED:
11:00 AM
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On 10/07/2022 at 9:30am Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced at this facility to conduct an Annual Visit. LPA Pascua met with Assistant Program Manager, Deirdre Murchison and explained the purpose of the visit. The purpose of the visit was to conduct a 1-year required visit. There are 56 clients who are currently enrolled in this program. Current census was current 0 as 16 consumers were out of the facility currently at an outing. There were two other staff members present at the time of this visit, Jane Johnson and Frankie Orona.
This facility has a central screening point equipped with hand sanitizer and masks available.
At approximately 9:40am, LPA Pascua initiated a tour with Assistant Program Manager(APM), Deirdre Murchison.
At 9:45am, LPA Pascua observed two front rooms near the entrance that were used for meetings and currently used as an isolation room for clients who may have symptoms. The other room was used for files and any administrative duties. Furniture, windows, and screens were observed to be in compliance at this time. Another room was identified as the Program Manager Office and was observed to be in compliance at this time.
At 9:50am, LPA toured the staff break room which is made inaccessible to the residents at all times. LPA observed one refrigerator and lockers for staff members use.
At 9:55am LPA toured the facility kitchen. LPA observed there be to a water heater under the sink which is made to be inaccessible to the clients in care. LPA observed cabinets for storage and three refrigerators that are used by the clients are in good repair. The First-Aid kit located in the kitchen was observed to have all the required components and was in compliance at this time.
At 10:00am, LPA identified two fire extinguishers that were located in the main hallway and classroom area. Fire extinguishers were serviced on 08/19/2022 by a local fire company, Fire Code.
At 10:05am, LPA toured the main room which is split into three classrooms by barriers. LPA observed there to be two restrooms. All client restrooms are maintained with soap and paper towels available for the clients. Hot water temperature was observed to be 106.5 degrees F.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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 2
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: APPLIED ABILITIES PROGRAM
FACILITY NUMBER: 397005196
VISIT DATE: 10/07/2022
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At 10:10am, LPA toured the 3 classrooms of the facility. The common areas used for clients were observed to be odor free. All furnishings were observed to be in good repair. LPA also identified additional storage in the back. It was observed that there were two locked cabinets that stored cleaning supplies which were made inaccessible to the clients in care.
At 10:20am, LPA Pascua observed there to be a locked medication cabinet under the front desk. Along with APM, Murchison the LPA reviewed, and compared client medication and medication dispensing logs.

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

LIC 308

LIC 400

LIC 500

LIC 610

As a result of this visit there were no deficiencies observed or cited during today's annual visit. An exit interview was conducted and a copy of the 809 and 809-C was provided to Assistant Program Manger, Deirdre Murchison.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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