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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801782
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:23:09 PM

Document Has Been Signed on 04/18/2024 02:23 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
Lookup Error,
, CA
FACILITY NAME:CO-OPFACILITY NUMBER:
486801782
ADMINISTRATOR/
DIRECTOR:		SIMMONS, SAMIKAFACILITY TYPE:
775
ADDRESS:320 CERNON STREETTELEPHONE:
(707) 449-9377
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 45CENSUS: 19DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Samika Simmons, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct an annual inspection and met with Samika Simmons, Administrator, and stated the reason for the inspection. LPA observed (10) staff members present along with (19) clients engaging in activities at the start of the inspection. Some clients require 1:1 supervision. The location is licensed for an adult day program for (45) clients. Most clients are ambulatory.

LPA the Administrator toured the interior and exterior of the facility, including the common activity rooms, a gym, classroom/training area, kitchen, and bathrooms. There were no immediate health, safety, or personal rights violations observed. The facility appeared to be clean and free from odors. There is a locked area for toxins and sharps in the kitchen. Bathrooms were clean and contained soap, paper products. Administrator to install a paper towel holder in one bathroom and post 20- second hand-washing poster by all sinks.

The fire extinguishers were last serviced 10/14/23 and monthly fire drills are conducted with staff and clients. Hot water measured 120*F in the kitchen. Emergency exits (3) were clear and accessible. The First Aid kit was missing scissors. There is sufficient PPE and paper products. Program Policy and Procedures and Personal Rights are posted along with an activity calendar.

LPA reviewed (3) client files. All files were organized and complete. Administrator to request the Regional Center provide current copies of service plans. There are (3) client that takes medication. The medication is locked in common area and documentation is maintained. P&I records were reviewed for (3) clients. Files were organized and funds on hand matched the documentation.

LPA reviewed (7) of (10) staff files. All staff is cleared/associated, has current First Aid/CPR certifications and has completed required annual training. Training is conducted monthly on pre-determined topics per regulation and includes driver’s training. The Administrator will provide documentation that training has been completed for the (30) required hours every 24 months- copy of regulation printed as requested.

cont on 809C-1...

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: CO-OP
FACILITY NUMBER: 486801782
VISIT DATE: 04/18/2024
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809C-1...Vehicle records were reviewed for all (4) facility vehicles. Documentation shows vehicles had recent maintenance in April 2024. The day program provides transportation for all clients to/from their residence.

LPA reviewed/approved the Infection Control Plan (also provided a blank LIC9282) and Emergency Disaster Plan. Administrator to complete an updated LIC610D. An updated copy of the lease agreement was obtained.

LPA requested updated Surety Bond policy, documentation of training for the Administrator, LIC500 and LIC308 be emailed to the LPA by 4/25/24.

There were technological delays in completing today's inspection.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, there are no deficiencies cited during today's inspection.

Exit interview. Copy of report provided to the Administrator.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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