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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005339
Report Date: 06/01/2022
Date Signed: 06/01/2022 12:12:28 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/01/2022 12:12 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:STARTING OUTFACILITY NUMBER:
397005339
ADMINISTRATOR:ANN FISLERFACILITY TYPE:
775
ADDRESS:41 W YOKUTSTELEPHONE:
(209) 476-1170
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 120CENSUS: 65DATE:
06/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Mia Chapman James - Program ManagerTIME COMPLETED:
12:20 PM
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Licensing Program Analysts (LPA's) Ruth Wallace and Renee Campbell conducted unannounced Required – 1 Year Annual Inspection Visit. LPA's met with Program Manager (PM) and stated the purpose of today’s visit. LPA's were allowed entry into the facility and was accompanied by PM throughout the inspection tour of the facility that is licensed to serve a total capacity of 120 clients today's census is 65 enrolled in remote alternative services. LPA's observed four of four staff present associated and cleared in Licensing Information System.
The facility is a Day Program that has not been operating in person services since March 2020 but have been providing remote services to clients via Zoom and other video programs. The are seven classrooms for activities, four restrooms, staff office, break room, kitchen and storage areas. LPA's observed tables and chairs to serve the capacity of the day program and promote social distancing. LPA's observed medications room locked with a medications cart to store centrally stored medications upon reopening. LPA's observed areas where staff prepare packets to be delivered to clients.
The physical plant was toured inside and outside to ensure the safety of the clients upon return. The temperature inside the facility was measured at 74*F which is within the required range of 68*F and 85*F. The hot water was measured at 107.2*F which is within regulatory range of 105*F and 120*F. LPA observed first aid kits was found not in compliance missing scissors and tweezers, current edition of a first aid manual approved by the American Red Cross, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA's observed a pull alarm system, newly purchased fire extinguisher(s) expire 5/14/2023, smoke and carbon monoxide detectors, central heating and air in the facility.
Upon a file review the following items were discussed to be submitted with any changes to LPA by 6/30/2022:
Articles of Incorporation
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Qualifications of Administrator
Emergency Disaster Plan LIC610D
Per the California Code of Regulations, Title 22, Division 6, no deficiencies observed or cited. Exit interview held with PM, copy of report given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2022
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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