<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800557
Report Date: 01/30/2023
Date Signed: 01/30/2023 02:49:55 PM

Document Has Been Signed on 01/30/2023 02:49 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:I.M.P.A.C.TFACILITY NUMBER:
486800557
ADMINISTRATOR:JOETTA GRIFFINFACILITY TYPE:
775
ADDRESS:2573 CLAY BANK ROAD, SUITE 12TELEPHONE:
(707) 862-2105
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 90CENSUS: 39DATE:
01/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Supervisor, Gabriela EchevarriaTIME COMPLETED:
03:00 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), Farhaan Sarangi arrived unannounced at I.M.P.A.C.T Adult Day Program for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by, Supervisor, Gabriela Echevarria, and was granted access into the facility. LPA observed no signs on the front door (See LIC 9102).

LPA and Program Supervisor toured the one story facility. Facility was found to be clean in good repair and at a comfortable temperature with all exits free from obstruction. The facility consists of a bistro, kitchen, three bathrooms, a computer room, Supervisors room and five activity rooms. Bathrooms contained grab bars, hygiene products and continence care products available for client use inside the closet and accessible. Hot water measured at 107 degrees in 3 of 3 clients bathrooms, 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 unless there is a party or special occasion. Facility does not assist with dispensing medication at the facility. Fire extinguishers were observed to be present with an inspection tag date of March 2022. First aid kit was inspected and found to be appropriate during the inspection. Carbon Monoxide and Smoke Detectors are hard wired to the fire station.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has sufficient PPE supplies. Facility has been PPE trained (gloves, face masks and how to wash hands).

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: I.M.P.A.C.T
FACILITY NUMBER: 486800557
VISIT DATE: 01/30/2023
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
26
27
28
29
30
31
32
LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
CHP inspections for the vans that transport clients
Fire Alarm system inspection
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of clients

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the facility Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3