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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800498
Report Date: 11/15/2024
Date Signed: 11/15/2024 11:50:21 AM

Document Has Been Signed on 11/15/2024 11:50 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/
DIRECTOR:		ALFREDO LACUATA JRFACILITY TYPE:
775
ADDRESS:1 FLORIDA STREETTELEPHONE:
(707) 644-0464
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 116CENSUS: 53DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Alfredo Lacuata, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an annual Required Inspection and met with Administrator Alfredo Lacuata. Client to staff ratios are typically 1:2 on site. Annual fees are current. There were 53 clients participating on site today with 28 staff providing direct supervision. Day program is open Monday through Friday from 8:00 am to 3:00 pm.

LPA/Administrator toured the facility at approximately 9:30 am, which was found to be clean, in good repair and comfortable temperature at 67 degrees F. The facility consists of a kitchen, 4 bathrooms, 4 activity rooms, an outdoor patio quiet area, and staff offices. Bathrooms contained necessary grab bars, hygiene products and continence care products available for client use. Hot water measured between 113.9 and 112.1 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by clients. Participants typically bring their own lunches and snacks are provided. All exits were found to be unobstructed and contained working auditory devices and mats. Medication is stored in a locked cabinet located in the kitchen in the medication cart, which was locked at the time of visit. All items that could constitute danger were found to be inaccessible at the time of the visit. Fire extinguishers were observed to be present with an inspection tag date of 11/28/23. Carbon monoxide detectors were tested and found to be working at the time of the visit. Smoke detectors are hard wired and are tested with fire sprinklers quarterly by Major Fire Systems Inc. Last inspection was completed on 9/18/2024. Last Disaster Drill conducted 10/15/2024. Transportation services is provided by R&D. LPA/Administrator inspected the vans used to transport participants, vehicles have current fire extinguishers and 1st aid kits. Facility have two nurses (LVN & RN) who are usually present eight hours a day to oversee medical needs and medication. A spot check of medications and their records were reviewed. Required postings were observed. Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MILESTONES ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 486800498
VISIT DATE: 11/15/2024
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Continued from LIC809...

LPA initiated file review at 10:0AM, A sample review of ten participants and five staff files. Participants have current care plans and medical assessments on file. All staff have current CPR/1st aid certificates and required training hours on file. Based on records review and interview with Administrator, the facility has inquired, but not requested exceptions for postural supports for 46 participants exceptions from the Department. Administrator was provided with a list of participants needing exceptions to be submitted to CCL, they have been actively working with the Department to process the exceptions needed for participants. During today's visit, LPA have a discussion with the Administrator regarding documentation needed as follow:

- A written statement indicating the client's name, their date of birth and the postural support(s) needed for an exception, detailing how the facility staff will ensure personal rights are maintained while using the postural support.

-A written statement from their responsible party and regional center agreeing to the use of postural support(s).

-A physician's report and/or medical orders supporting the need of postural support(s).

-Current care plan for each participant indicating how facility staff will assist with postural support(s).

Administrator agreed to submit pertinent documents to CCL for review by not later than 12/15/24. Administrator provided updated copies of the following: LIC500- Personnel Report, LIC308- Designation of facility responsibility and control of property.

No deficiencies cited during today's visit. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
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