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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802051
Report Date: 05/05/2022
Date Signed: 05/05/2022 12:14:01 PM

Document Has Been Signed on 05/05/2022 12:14 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:DIFFERENT STROKESFACILITY NUMBER:
486802051
ADMINISTRATOR:LOPEZ FOX, PAMELAFACILITY TYPE:
775
ADDRESS:825 EMPIRE STREETTELEPHONE:
(707) 428-3515
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 15CENSUS: 12DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Pamela Lopez Fox, Administrator TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Pamela Lopez Fox, Administrator. Supervisor Joseph Greene was also present. The annual inspection is focused on the Infection Control procedures and practices of this Adult Day Program. All staff wore masks during this visit.
Facility has a screening station with sign-in sheet and COVID questionnaire. LPA was screened for COVID-19 symptoms and LPA's temperature was taken upon arrival. Staff have CPR/first aid certifications. Fire extinguisher was charged and serviced 12/13/2021. LPA conducted a walk-through of the facility with administrator & supervisor. Different Strokes is currently providing in-person services Monday & Tuesday and starting on 05/16/22 the facility will be open Monday - Thursday for in-person services. The facility also provides alternative services such as activity bags, outside activities, virtual classes (cooking, Tai chi, music, animal therapy, educational, etc) and phone calls. LPA observed COVID-19 precaution postings; and soap & paper towels were observed in the bathrooms. Staff clean the facility daily; LPA observed a staff cleaning log in each room. The facility does not handle client cash resources or medication.
The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, face shields, and surgical masks. Staff have received training on the following topics: infection prevention, symptoms, transmission and PPE use. Staff and client's temperatures are taken daily and documented. The facility has completed a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 and submitted to the California Department of Social Services, Community Care Licensing.

LPA obtained the following updated records for the facility file during today's visit:
    ยท LIC 308 Designation of Facility Responsibility; LIC 500 Personnel Report; LIC 610D Emergency Disaster Plan; LIC 9020 Register of Facility Clients; Copy of Property Tax document showing control of property.
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: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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