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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800557
Report Date: 03/21/2024
Date Signed: 03/21/2024 12:36:21 PM

Document Has Been Signed on 03/21/2024 12:36 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: 43DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Gabby Echevarria, Program DirectorTIME COMPLETED:
12:45 PM
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On 3/21/2024 Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr inspection for this facility and met with Program Director, Gabby Echevarria. The facility currently provides care for 43 clients, 22 of which were at the facility at the time of visit. The facility is currently conducting full in-person service program.

LPA continued with a tour of the facility with Director; 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 March 12, 2024. Carbon monoxide detector located in main common area was tested and found to be in working order.
LPA was informed that an outside agency had conducted a fire inspection in 2023 and had inspected safety devices including sprinkler system, alarms and smoke detectors. Program Director to provide LPA with a copy of the fire inspection report.

Clients were observed to be engaged in various group activities including, large group discussion, arts & crafts, one-on-one classes and other options to choose during program hours. During the visit, several clients were on public outings with staff. Some outings include visits to public parks, trails and local ranches. Facility designates several Direct Support Staff to accompany clients by group. Staffing was found to be sufficient. Clients observed to have positive relationship with staff continuously engaging and participating with clients. LPA was informed that clients currently provide their own meals with snacks provided throughout the day. Facility primarily holds outdoor activities during outings and also has a large outdoor parking lot area located in the rear of the building for client use. Toxins, cleaning supplies and other potentially dangerous items are stored in a designated cleaning supply closet inaccessible to clients. All other storage closets and containers holding items that could potentially be a danger to clients if accessible were all found to be locked and secured.

Continue onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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: I.M.P.A.C.T
FACILITY NUMBER: 486800557
VISIT DATE: 03/21/2024
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Water temperature at faucets accessible to clients measured at 105.0 degrees F which is within Title 22 regulations requiring water measurements between 105 and 120 degrees F. LPA conducted a file review of client records and found all items including, individual service plans and physician's report to be in order. LPA conducted sample file review of staff records and found staff to have sufficient CPR & 1st Aid training completed. Recently hired staff have also completed all onboard training and meet hourly training requirements.

LPA provided recommendation on file organization for staff training records and client care records. Technical Advisories Issued. In addition, facility will need to update Emergency Disaster Plan.

LPA requested the following documents be sent to CCL by COB 4/21/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Fire Inspection Report

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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