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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800498
Report Date: 11/30/2021
Date Signed: 11/30/2021 03:11:33 PM

Document Has Been Signed on 11/30/2021 03:11 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MILESTONES ADULT DEVELOPMENT CENTERFACILITY NUMBER:
486800498
ADMINISTRATOR:TERRI ROWLANDFACILITY TYPE:
775
ADDRESS:1 FLORIDA STREETTELEPHONE:
(707) 644-0464
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 116CENSUS: 80DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Fred Lacuata, AdministratorTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Fred Lacuata (FL). The facility is licensed by Milestones of Development INC. and currently provide services for 80 clients; 24 clients participate on Monday/Wednesday, 21 clients participate Tuesday/Thursday and 38 of which currently participate remotely. Program was completed for the day and clients had left facility at the time of visit. Facility has contracted with R&D Transportation Services for client transportation. Fire Inspection was last conducted on 8/5/2021 and Carbon Monoxide detectors tested and found to be functional.

LPAs arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire extinguishers were found to be last charged 12/10/2021.

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters are readily available. Facility has a station at main entrance with a sign in sheet in place, hand sanitizer and other items designated for clients and staff. Staff and clients will be screened on a daily basis and recorded per Administrator, clients bring individual lunches for contamination measures. Facility has modified activities to ensure social distance practices.

LPAs requested for facility updated records which will be send via email:
Emergency Disaster Plan
Transportation Procedures
Theft and Loss Policy

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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