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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801931
Report Date: 11/03/2022
Date Signed: 11/03/2022 11:59:16 AM

Document Has Been Signed on 11/03/2022 11:59 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:DUNGARVIN CALIFORNIA LLCFACILITY NUMBER:
486801931
ADMINISTRATOR:NOWLIN, JERAMIEFACILITY TYPE:
775
ADDRESS:310 E MONTE VISTA AVE STE ATELEPHONE:
(707) 449-3722
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 45CENSUS: 28DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Jeramie NowlinTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Katrina Walters arrived unannounced to conduct a Annual Required - 1 Year inspection and met with Administrator, Jeramie Nowlin. At the time of inspection there were 5 DSP staff present who were supporting 14 clients. The annual inspection is focused on the Infection Control procedures and practices of this Adult Day Program Facility. This day program is offering 3 sessions for clients and alternative services for clients who are not able to attend.

The day program is held out of 3 large activity rooms, in addition to a music room, art room, activity center, exercise room, quarantine space and resource center. There are also dedicated bathrooms for clients, staff office, kitchen, and storage areas for program use.

Day program clients have a variety of social interaction which include: arts & crafts, musical instruments, cooking classes, zoom class..etc Clients lunches are stored in the kitchen, and provided to clients during lunch time. In the event that a client doesn't have their lunch or wants an additional snack, the facility staff are able to supply them with meals.

LPA observed that both the bathroom and kitchen were sanitary and in good repair, with hand washing supplies and paper towels. All exits were unobstructed. Facility has a COVID-19 screening station (visitor sign-in sheet, COVID questionnaire, thermometer, hand sanitizer).The facility has an ample supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns and surgical masks. There is PPE stored in a cabinet in each room, along sanitization stations upon entering each room. Staff and client's temperatures are taken daily and documented prior to entering the facility.
Continued on 809 C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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: DUNGARVIN CALIFORNIA LLC
FACILITY NUMBER: 486801931
VISIT DATE: 11/03/2022
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LPA reviewed 4 staff records with Administrator. All staff records were completed with vaccination records. Additionally Administrator showed LPA meeting notes in which staff were provided with infection control training. All staff wore face mask during the visit.

LPA observed an updated emergency disaster plan on the wall. Facility did not have a complaint poster. Administrator to provide proof that they have purchased a complaint poster and that it's posted by 11/17/22. LPA is also requesting a copy of their emergency disaster and LIC 500.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
**No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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