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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202769
Report Date: 06/16/2026
Date Signed: 06/16/2026 12:19:16 PM

Document Has Been Signed on 06/16/2026 12:19 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, 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: 4DATE:
06/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Staff S1, Yahna DickTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with staff S1, Yahna Dick, referred to as S1 . During the visit, LPA observed 1 client and 1 staff. LPA explained the purpose of the visit.

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

S1 informed LPA the facility does not provide meals to clients. 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 72 degrees F, and hot water temperature was measured at 108 degrees F in bathrooms.

Fire extinguisher was serviced in February 22, 2026. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by February 22, 2026 by Cintas.

LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on June 14, 2026. LPA reviewed facility disaster plan, which was last reviewed/updated on June 16, 2026

LPA reviewed 3 client files. LPA requested to review client C1-C3's written medical assessment. S1 stated the facility does not have a written medical assessment for Clients C1-C4.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2026
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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Document Has Been Signed on 06/16/2026 12:19 PM - It Cannot Be Edited


Created By: Manuel Monter On 06/16/2026 at 10:59 AM
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: 06/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records reviewed, the licensee did not comply with the section cited above. LPA reviewed 3 client files. LPA requested to review client C1-C3's written medical assessment. S1 stated the facility does not have a written medical assessment for Clients C1-C4. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2026
Plan of Correction
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S1 stated she will send the Department a written plan on how the facility will obtain a written medical assessment for clients C1-C4. S1 stated she will send the POC to the Department by POC due date, June 23, 2026.
Type B
Section Cited
CCR
82019(e)(4)
82019 Criminal Record Clearance (e)(4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 82019.1(r), unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the day program.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA cross reference staff S2's name and noted that S2 was not associated to the facility. S2 has been working at the facility since July 1, 2025. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2026
Plan of Correction
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S1 stated that he/she will ensure that all staff working with the clients are associated with the facility prior to starting their employment at the facility. S1 will send proof of correction to LPA by the POC due date of June 23, 2026
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:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


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: 06/16/2026
NARRATIVE
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LPA reviewed 3 staff files. LPA cross reference staff S2's name and noted that S2 was not associated to the facility. S2 has been working at the facility since July 1, 2025.

LPA cross referenced Staff S3's name and noted he/she does not appear in the Guardian Criminal background clearance. S1 stated they were under the assumption that S3 had his/her fingerprints at his/her previous employment. S1 stated S3 has been working at the day program since June 8, 2026.

LPA requested to review Staff S3's heath screening. LPA was not provided S3's health screening to review. S1 stated S3 is going to get his/her health screening tomorrow.

Based of interview and record review a civil penalty will be assessed for 1 out 3 staff (S2) who is not associated with the facility. An immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for maximum of five (5) days by the Department. For a total of $500.00

Based of interview and record review a civil penalty will be assessed for 1 out 3 staff (S3) who does not have a California clearance shall result in an immediate assessment of civil penalties of $500

Deficiencies cited during today's visit. This report was reviewed with Staff S1, Yahna Dick and a copy of the signed report was provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/16/2026 12:19 PM - It Cannot Be Edited


Created By: Manuel Monter On 06/16/2026 at 11:46 AM
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: 06/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)(2)
82019 Criminal Record Clearance (e)(2) Obtain a California clearance or a criminal record exemption as required by the Department; or

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on record Review, the licensee did not comply with the section cited above. LPA cross referenced Staff S3's name and noted he/she does not appear in the Guardian Criminal background clearance. S1 stated they were under the assumption that S3 had his/her fingerprints at his/her previous employment. S1 stated S3 has been working at the day program since June 8, 2026. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2026
Plan of Correction
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During today's visit, S1 asked S3 to leave the facility. S1 stated S3 will do live scan today, June 16, 2026. S1 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. S1 will send proof of correction to LPA by the POC due date of June 17, 2026
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/16/2026 12:19 PM - It Cannot Be Edited


Created By: Manuel Monter On 06/16/2026 at 11:52 AM
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: 06/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065(g)(1)
82065 Personnel Requirements (g) (1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results
for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. LPA requested to review Staff S3's heath screening. LPA was not provided S3's health screening to review. S1 stated S3 is going to get his/her health screening tomorrow. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2026
Plan of Correction
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S1 stated S3 will get a health screening on June 17, 2026. S1 stated she will send a copy to the Department by June 23, 2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


LIC809 (FAS) - (06/04)
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