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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202975
Report Date: 10/27/2021
Date Signed: 10/27/2021 04:08:42 PM

Document Has Been Signed on 10/27/2021 04:08 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:UNITED CEREBRAL PALSY, PROGRAM WITHOUT WALLSFACILITY NUMBER:
397202975
ADMINISTRATOR:JOANNE JOHNSONFACILITY TYPE:
775
ADDRESS:6709 PLYMOUTH ROAD, SUITE CTELEPHONE:
(209) 956-0290
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 45CENSUS: 32DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Amanda HartTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required – 1 Year inspection on 10/27/2021 at 3:25pm. LPA met with Designated Staff Amanda Hart and stated the purpose of today’s visit. LPA contacted Program Director Shirley Ridoloso Chanthavong prior to today's visit for COVID screening, COVID screened upon entry. LPA was allowed entry into the facility and was accompanied by Amanda throughout the inspection tour of the facility that is licensed to serve a total capacity of 45 clients today's census is 32 enrolled in remote alternative services of which 4 are coming on site Monday, Wednesday, and Friday. LPA observed one of one staff present associated with criminal record clearance in Licensing Information System.

The facility is a Day Program that has been operating in person services since July 2021 and have been providing remote services to clients via Zoom, other video programs and packets. LPA observed tables and chairs to serve the capacity of the day program and promote social distancing.The physical plant was toured inside to ensure the safety of the clients. LPA observed chemicals and knives locked inaccessible to clients. The temperature inside the facility was measured at 72*F which is within the required range of 68*F and 85*F. The hot water was measured at 109*F within regulatory range of 105*F and 120*F. LPA observed first aid kit was found in compliance. LPA observed fire extinguisher last inspected on 3/18/2021, smoke and carbon monoxide detectors, central heating and air in the facility. Last fire drill was conducted on 9/20/2021.

Upon a file review the following items were discussed to be submitted to CCL:
Qualifications of Program Director
Personnel Report LIC500

Per the California Code of Regulations, Title 22, Division 6, no deficiencies observed or cited. Exit interview held, copy of report given. A signature on this form acknowledges receipt of these documents.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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