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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800498
Report Date: 10/13/2022
Date Signed: 10/13/2022 11:31:59 AM

Document Has Been Signed on 10/13/2022 11:31 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MILESTONES ADULT DEVELOPMENT CENTERFACILITY NUMBER:
486800498
ADMINISTRATOR:ALFREDO LACUATA JRFACILITY TYPE:
775
ADDRESS:1 FLORIDA STREETTELEPHONE:
(707) 644-0464
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 116CENSUS: 70DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Fred Lacuata, AdministratorTIME COMPLETED:
11:40 AM
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On 10/13/2022, 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 70 clients; 22 clients participate on Monday/Wednesday, 24 clients participate Tuesday/Thursday and remainder of which currently participate remotely. Program was in operation with 20 clients present at the time of visit. Facility has contracted with R&D Transportation Services for client transportation with COVID safety protocols for client symptoms assessment prior to boarding facility vehicles as well as arrival to the program site. Fire Inspection was last conducted on 8/5/2021. Recent inspection delayed due to facility temporary hold of operation due to COVID prevention.

LPA 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. LPA observed all clients to be engaged in various activities with fire extinguishers were found to be last charged 12/1/2021. Staff and supervisors also provide remote services and direct in person care to clients outside of the day program. Activity supplies are also provided to clients who participate remotely for full engagement and participation. Staff appear to be assisting clients and providing support during a tour of the facility.

Cleaning supplies were all located in a secured closet found in separate activity room. Restrooms accessible to clients were inspected and found to be in clean and sanitary condition. Kitchen and food supply areas were also inspected and found to be in order with food items properly stored.
Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MILESTONES ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 486800498
VISIT DATE: 10/13/2022
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Infection Control:
Facility has submitted a infection control plan to CCLD for review. 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 are 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 in which various instructors provide both mental and physical stimulating programs virtually. Facility continues to test 25% of staff monthly, with program mitigation plan for facility temporary closures in cases of positive exposure.

LPAs requested for facility updated records to be submitted to CCLD by COB 10/20/2022:
- 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: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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