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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803155
Report Date: 02/07/2023
Date Signed: 02/07/2023 10:20:36 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/07/2023 10:20 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:LEARNING WITHOUT LIMITS DAY PROGRAMFACILITY NUMBER:
486803155
ADMINISTRATOR:DELACRUZ, ELFLEDAFACILITY TYPE:
775
ADDRESS:244 TRAVIS COURTTELEPHONE:
(707) 759-4579
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY: 45CENSUS: 8DATE:
02/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Assistant Administrator, Edith Briones,TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced for the purpose of conducting a Follow-up Required 1 year inspection due to a recent inspection that was conducted on January 31, 2023. During that Required 1 year inspection, Licensing Program Analyst (LPA), Katrina Walters inspected and performed the Required 1 year inspection. However, due to computer issues, the Required 1 year inspection was not populating in the Field Automation System (FAS). LPA was greeted at the door by, Edith Briones, and was granted access into the facility.

LPA and Assistant Administrator toured the facility. Facility is a one floor building that was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire extinguisher was last inspected and charged on August 2022. Smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. First aid kit was inspected and found to be appropriate during the inspection. Hot water temperature was checked and measured at 107 degrees in 2 of 2 clients bathrooms and is within Title 22 regulation of 105-120 degrees. Personnel records and client records are stored at the facility office area. The main floor includes a large activity room with two offices located at the front entrance. Activities are pre-planned. Client & staff records, medication, first aid supplies, and toxins are locked and inaccessible on this level. Clients will bring their own food and food will be provided for plan celebrations. Facility will not handle P&I. LPA requested the following documents to be sent to Community Care Licensing:
LIC 500- Personnel Report. LIC 308- Designation of Responsibility, LIC 309- Administrative Organization, LIC 400- Affidavit regarding Client Cash Resources, Fire Alarm System test, Updated facility sketch, Updated Emergency Disaster Plan (LIC 610D), Surety Bond, Most up-to-date Liability insurance, Control of Property, Register of residents.

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 facility Program Manager.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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: LEARNING WITHOUT LIMITS DAY PROGRAM
FACILITY NUMBER: 486803155
VISIT DATE: 02/07/2023
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LPA requested the following documents to be sent to Community Care Licensing:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Fire Alarm System test
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents

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

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC809 (FAS) - (06/04)
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