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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202975
Report Date: 10/25/2022
Date Signed: 10/25/2022 09:59:00 AM

Document Has Been Signed on 10/25/2022 09:59 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
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: 35DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Amanda HartTIME COMPLETED:
10:00 AM
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On 10/25/22 at approximately 8:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year visit. LPA Jensen met with Program assistant Manager Amanda Hart and explained the purpose of today's visit.

The facility is a day program that is currently serving approximately 10 or less clients per day and is in the process of transitioning back in to full in person services after pausing due to pandemic related restrictions. Several clients receive remote services. The facility was observed to be sanitary, and equipped with adequate furniture and lighting. LPA Jensen observed several activities in progress for client engagement and skill development. The temperature in the facility was set at 71 degrees which falls within the required regulatory range of 68-85 degrees. The water temperature was measured at 109.9 degrees and falls within the required range of 105-120 degrees. The first aid kit was observed to be complete with scissors, thermometer, tweezers and various wound dressings. The fire extinguisher was last serviced in March of 2022 and is in compliance. LPA Jensen reviewed emergency procedure drill logs and fire drill logs.

The facility entrance is equipped with a visitor sign in sheet, staff COVD screening log and client COVID screening log. COVID signs, a thermometer and hand sanitizer are also set up at the entrance table. There is a large main room for activities, two client bathrooms, a changing room, and kitchen that also functions as a zoom conference room. Medications, toxins and cleaning supplies were observed to be locked and inaccessible to clients. The infection control inspection tool was utilized during the course of this inspection. A separate room has been designated for quarantine if needed and a cart has been set up outside the room with appropriate PPE and supplies. 2 staff files were reviewed and 2 client files were reviewed and found to be complete.

No deficiencies were cited during the course of today's visit. An exit interview was conducted and a copy of this report was handed to Amanda Hart.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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