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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005196
Report Date: 10/14/2024
Date Signed: 10/16/2024 07:38:19 AM

Document Has Been Signed on 10/16/2024 07:38 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:APPLIED ABILITIES PROGRAMFACILITY NUMBER:
397005196
ADMINISTRATOR/
DIRECTOR:		LYNN HOGUEFACILITY TYPE:
775
ADDRESS:324 E. 11TH STREET., STE. C&DTELEPHONE:
(209) 956-0290
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 60CENSUS: 47DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Rocel CooperriderTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 10/14/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was met by Program Director (PD) Rocel Cooperrider and explained the purpose of the visit.

This facility is licensed to serve 60 clients of which 10 my non-ambulatory. There were 5 other staff members present at this time, A brief interview with PD Cooperrider was conducted.
Current census was 47. 2 of 47 residents were currently obtaining services remotely. There were 5 other staff members present at this facility.

LPA reviewed 5 client and 5 staff files. All client and staff files were current and up to date.
A tour of the facility was conducted with PD Copperrider.
LPA Pascua observed two front rooms near the entrance that were used for meetings. 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.
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.
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.
LPA identified two fire extinguishers that were located in the main hallway and classroom area. Fire extinguishers were serviced on 10/19/2023 by Butch Young Fire Equipment, INC.
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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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: APPLIED ABILITIES PROGRAM
FACILITY NUMBER: 397005196
VISIT DATE: 10/14/2024
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Hot water temperature was taken in the kitchen, and two resident bathrooms. In the kitchen the hot water temperature was measured to be at 56 Degrees, bathroom one was measured to be at 67.3 degrees and bathroom 2 was measured to be at 118.1 degrees.

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.

LPA Pascua observed there to be a locked medication cabinet under the front desk.

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

A technical violation was provided to the following 80088(e)(1).
LPA discussed that the water faucets did not automatically maintain hot water temperature within the require regulatory range of 105-120 degrees at all faucets.

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 the facility at the end of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC809 (FAS) - (06/04)
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