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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801782
Report Date: 12/12/2023
Date Signed: 12/12/2023 12:20:56 PM

Document Has Been Signed on 12/12/2023 12:20 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:CO-OPFACILITY NUMBER:
486801782
ADMINISTRATOR:SIMMONS, SAMIKAFACILITY TYPE:
775
ADDRESS:320 CERNON STREETTELEPHONE:
(707) 449-9377
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 45CENSUS: 17DATE:
12/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jacquelyn BarkumTIME COMPLETED:
12:30 PM
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Licensing Program Analyst Leibert, while conducting an investigation alleging that reporting requirements were not met following an incident where client (C1) was injured, noted a deficiency not included in the initial complaint. C1 was administered first aid by staff following the accident but did not call for or, transport for, a medical or dental assessment. Such assessment was necessary to evaluate the extent of injuries and the possibility of other injuries not readily observed by staff.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Report left.

SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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 2
Document Has Been Signed on 12/12/2023 12:20 PM - It Cannot Be Edited


Created By: David Leibert On 12/12/2023 at 12:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CO-OP
FACILITY NUMBER: 486801782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2023
Section Cited
CCR
82075(a)

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Health-Related Services. The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. *** Based on documents and
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Administration shall review the requirements of 82075 and provide a written plan on how Program will comply going forward. Plan to be submitted to CCL by POC date in order to clear the deficiency.
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statements, requirement not met, evidenced by: C1 fell on 10/26/2023, sustained 2 fractured teeth, cut lip which bleed. Staff administered first aid but did not ensure that C1 received necessary medical or dental services. This posed an immediate risk to C1’s health.
POC:
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Carla Martinez
LICENSING EVALUATOR NAME:David Leibert
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
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