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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202769
Report Date: 06/17/2024
Date Signed: 06/17/2024 11:37:11 AM

Document Has Been Signed on 06/17/2024 11:37 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SPREAD YOUR WINGS, LLCFACILITY NUMBER:
435202769
ADMINISTRATOR/
DIRECTOR:		DUMBUYA, ANDREW SERRYFACILITY TYPE:
775
ADDRESS:570-590 BLOSSOM HILL RDTELEPHONE:
(408) 401-2984
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 27CENSUS: 0DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Staff Jae SuhTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff S1, Jae Suh. During the visit, LPA observed 0 residents and 1 staff. The facility does not have any clients admitted to the day program pending SARC vendorization.

LPA toured the facility inside out with S1 which included the two restrooms, reception area, open area and kitchen. The front yard and backyard were inspected. There was no obstruction to block the walkways.

S1 stated the facility does not provide meals to residents. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 106 degrees F in both resident bathrooms.

Fire extinguisher was serviced in March 20, 2024. The facility has a combination carbon monoxide and smoke detector connected to a central fire alarm system. This system is monitored by an independent fire alarm service vendor.

LPA reviewed facility records for staff. LPA conducted interviews with 1 staff. LPA spoke with ADM. ADM stated they are in the process of submitting a change of capacity. ADM stated he will send the documentation for the change of capacity by the end of the month. ADM stated S1 could sign on his behalf.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SPREAD YOUR WINGS, LLC
FACILITY NUMBER: 435202769
VISIT DATE: 06/17/2024
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LPA requested a copy of the following documents to be sent to the Department by June 24, 2024.
1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. LIC200, please update (i.e., new phone numbers etc), if necessary.
6. Qualifications of Administrator (Certificate)
7. Please submit copy of surety bond
8. Please review your facility program for updates (incorporating new laws and/or regulations)

No deficiencies cited during today's visit. This report was reviewed with Staff Jae Suh and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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