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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801931
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:44:19 PM

Document Has Been Signed on 10/30/2023 02:44 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: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: 30DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Program Manager, Jeramie NowlinTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Dungarvin California LLC for the purpose of conducting a Required 1 year inspection. LPA met with Program Manager, Jeramie Nowlin, and was granted access into the facility. LPA observed 5 staff members at the facility.

LPA and Program Manager toured the facility which was found to be clean, in good repair, at a comfortable temperature with all exits free from obstruction. The facility consists of a kitchen, 4 bathrooms, 3 class rooms, a quiet area, and two staff offices. Bathrooms contained necessary grab bars, hygiene products and continence care products available for for client use. Hot water measured at 115 degrees F 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. Should clients forget their lunch staff will purchase or prepare a lunch for them. All items that could constitute danger were found to be inaccessible at the time of the inspection. Medications were centrally stored and locked in the Program Managers office. 2 of 2 Medication Orders were reviewed during the inspection and found to be appropriate. First Aid Kit was inspected and found to be appropriate during the inspection. Fire extinguishers were observed to be present with an inspection tag date of October 2023. Fire Safety inspection was completed which included a testing of the Carbon Monoxide Detectors and Smoke Detectors on October 26, 2023. A sample review of 5 client and 5 staff records was conducted and were found to be appropriate during the review. Vehicle inspection and maintenance logs are maintained and were observed to be kept on a daily basis for all vehicles transporting clients. A sample review of 5 staff records were reviewed and were found to be appropriate. Staff and client interviews were conducted. First Aid/CPR Cards were active for all staff members.

Infection Control Plan is currently being updated and will be sent to the LPA. Emergency Disaster Drill was conducted on September 2023. Emergency Disaster Plan was discussed with the Program Manager. (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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: 10/30/2023
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LPA requested the following documents to be sent:

LIC 500-Personnel Report
LIC 308-Designation of Responsibility
Liability insurance
Control of Property
Client Roster
Staff Roster
Infection Control Plan

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

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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