435202769-1-28-2026-26-AS-MPAA-DQS3HX-20260128171641

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202769
Report Date: 01/28/2026
Date Signed: 01/28/2026 05:17:11 PM

Document Has Been Signed on 01/28/2026 05:17 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	SPREAD YOUR WINGS, LLC		FACILITY NUMBER:	435202769
ADMINISTRATOR/ DIRECTOR:	DUMBUYA, ANDREW SERRY		FACILITY TYPE:	775
ADDRESS:	570-590 BLOSSOM HILL RD		TELEPHONE:	(408) 401-2984
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY: 27		CENSUS: 3	DATE:	01/28/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:26 PM
MET WITH:	Yahna Dick - Executive Director		TIME VISIT/ INSPECTION COMPLETED:	06:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LIcensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced case management - other inspection visit to verify if the facility is operational or not. The facility is a licensed adult day program serving adults 18 and over and accept clients who are ambulatory. At 1:06 p.m. LPA arrived at the facility and walked towards the front area, and observed multiple entry door with address 570, 572, 574 and 590. LPA observed the suites 574 and 590 are being renovated. LPA walked towards the door number 570 and 572, LPA observed people inside, went in and was greeted by the program manager (PM) who stated that the facility is an Adult Day Program (ADP) and confirmed with LPA that the name of the ADP is Spread Your Wings. LPA Partoza, provided identification and introduced self and stated the purpose of the visit. LPA observed 1 (one) client with a staff. 5 minutes later, LPA was met by Executive Director (ED) Yahna Dick. Based on observation, the facility is operational. PD stated the facility currently has three (3) clients. At 2:01 p.m. ED called licensee (LIC). LPA was able to speak with LIC and reinstated the purpose of the visit. LIC Andrew Dumbuya stated that the facility received their vendorization from San Andreas Regional Center (SARC) in November of 2025, and started to accept clients early December of 2025. LIC stated that during the annual inspection conducted in June of 2025, they were not operational. LIC stated that he/she transitioning the day to day operation responsibility to his/her associate by the name of Jae Suh. LPA reminded LIC the importance of notifying the Community Care Licensing (CCL) of any changes per California Code of Regulations (CCR) Title 22 82061(a) Reporting requirements. page 1 of 2 see LIC 809

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 01/28/2026

NARRATIVE

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LPA discussed with LIC annual renewal fees. LPA was able to confirm LICs email address and phone number when ED called LIC and picked up. Based on record review and interview LICs email and phone number on record is the same. LPA handed over to ED the Annual Fee Renewal notification letter. The letter is for the LIC to pay the renewal fee that was overdue amounting to $228.00.

At 3:00 p.m. LPA requested for the client and staff roster. LPA reviewed 3 client file and 2 staff file.
Based on record review and interview, 3 out of 3 clients does not have the medical assessment (LIC 602), and proof of cleared TB test. ED stated they do not handle cash in the facility, does not plan to administer medication and no personal valuables to be kept in the facility premises.

LPA verified the status of the 3 out of 3, staff for fingerprint and criminal background clearance. Based on record review and interview, 3 Out of 3 staff are not associated with the facility. S1 was hired on October of 2025 and started to work at the facility on November 2025, S2 was hired by the facility on December of 2024 and started to work at the facility on June of 2025. S3 was hired and started to work January 2024. LIC stated that he/she did not know that facility staff needs to be associated to the facility. 3 out of 3 staff (S1 to S3) have fingerprint clearance on record, however, LIC did not submit a request to transfer 3 out of 3 staff's criminal record clearance for the adult day program (ADP).

Deficiencies are cited during today's visit based on California Code of Regulation (CCR) Title 22, 82019 Criminal Record Clearance (e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 82019.1(r)...

Based of interview and record review a civil penalty will be assessed for 3 out 3 staff (S1 to S3) who are not associated with the facility and no approved transfer of a criminal record exemption on record; pursuant to 82019 (g) Violation of Section 82019(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for maximum of five (5) days by the Department. $500 x 3 (S1 to S3) for a total of $1,500.00 (see LIC 809D).

An exit interview was conducted with Executive Director Yahna Dick and a copy of the report and appeals rights were provided. end of report page 2 of 2.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/28/2026 05:17 PM - It Cannot Be Edited

Created By: Maria Partoza On 01/28/2026 at 04:35 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SPREAD YOUR WINGS, LLC	FACILITY NUMBER: 435202769
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/29/2026 Section Cited CCR 82019(e)	1 2 3 4 5 6 7	82019 Criminal Record Clearance (e) Prior to working...in a licensed day program, all individuals subject...to criminal record review ... shall ... (4) Request and be approved for a transfer of a criminal record exemption: This requirement is not met as evidenced by	1 2 3 4 5 6 7	ED stated that he/she will ensure that all staff working with the clients are associated with the facility and have fingerprint and background clearance prior to starting their employment at the facility. ED will send proof of correction to LPA by the POC due date of 01/29/2026.
	8 9 10 11 12 13 14	Based on 3 out of 3 staff record review. LIC did not request for a transfer or criminal record exemption for S1, S2, S3. S1, S2, S3 are not associated with the facility and have been working at the facility prior to 11/2025, S3 was hired in 1/2024, S2 was hired in 12/2024 & S2 was hired on 10/2025.	8 9 10 11 12 13 14	con't. Which pose/poses an immediate health safety and personal rights risks to persons in care.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/28/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

LIC809 (FAS) - (06/04)

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