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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803403
Report Date: 11/22/2024
Date Signed: 11/22/2024 12:29:38 PM

Document Has Been Signed on 11/22/2024 12:29 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:DAYS OUTFACILITY NUMBER:
486803403
ADMINISTRATOR/
DIRECTOR:		RICHARD,TROYFACILITY TYPE:
775
ADDRESS:72 MARINA CENTERTELEPHONE:
(707) 592-6546
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 15CENSUS: 15DATE:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Troy Richard, Licensee/DirectorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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At approximately 8:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Required - 1 Year inspection and met with Troy Richard, Licensee/Director. Facility provides in-person services, Monday through Friday from 9:30 AM - 1:30 PM. The facility is vendored with North Bay Regional Center (NBRC) and all the clients have a service coordinator. Transportation services are coordinated by NBRC.

At approximately 9:15 AM, LPA conducted a walk-through of the facility with Licensee and observed the following: Clients were arriving to the program for the day. LPA was informed that facility maintains mostly a 1:3 staff to client ratio. LPA observed a weekly schedule of activities, events, learning opportunities, and outings planned, these include, arts and crafts, movies, music, cooking, bowling, social time, shopping, library trips, lunch outings, holiday celebrations, and more.

LPA observed unobstructed exits and chemicals and other items which could pose a risk to clients in care stored in locked cabinets and closets. Soap & paper towels were available in facility bathrooms. Water temperatures in all bathrooms tested within the allowable range of 105-120 degrees Fahrenheit per Title XXII regulations. LPA observed the facility's first aid kit, PPE, emergency supplies, non-perishable foods, and water. Fire extinguishers were observed charged and were last serviced 5/2024. Smoke and carbon monoxide detectors were tested and operational. LPA was informed the facility does not manage or store medications or client cash resources.

At approximately 9:50 AM, LPA conducted file review of 5 staff files and 5 client files. 2 of 5 staff files reviewed were observed missing 2 or more of the required documents per regulation, (see LIC809D). 5 of 5 staff files reviewed had proof of current CPR and First Aid training certificates. 5 of 5 client files reviewed had current Needs and Services Plans but all were observed unsigned by either the client or their responsible party.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: DAYS OUT
FACILITY NUMBER: 486803403
VISIT DATE: 11/22/2024
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Continued from 809...

LPA advised Licensee to ensure all client care plans are reviewed with each client and/or their responsible party no less than annually and shall be signed and dated. 2 of 5 client files reviewed were observed missing 1 or more additional documents as required per regulation, (see LIC809D).

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 Personnel Report (updated)

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Appeal rights were given. Exit interview conducted with Licensee whose signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2024 12:29 PM - It Cannot Be Edited


Created By: Julie Florio On 11/22/2024 at 11:58 AM
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: DAYS OUT
FACILITY NUMBER: 486803403

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in ensuring that staff files have all the required documentation per regulation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2024
Plan of Correction
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Licensee to submit proof of negative TB results for Staff 1 (S1) and Staff 2 (S2) to CCL by POC due date 12/23/2024.

Licensee to submit self-certification that they have ensured that all the remaining required documentation, including proof of health screenings and training hours, is present in all staff files to CCL by POC due date 12/23//2024.
Type B
Section Cited
CCR
82070(d)
Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in ensuring that client files have all of the required documentation per regulation, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2024
Plan of Correction
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Licensee to submit proof of negative TB results for Client 1 (C1) to CCL by POC due date 12/23/2024.

Licensee to submit self-certification that they have ensured that all the remaining required documentation is present in all client files to CCL by POC due date 12/23/2024.

Licensee to submit self-certification that they have ensured that all of the client Needs and Services Plans have been reviewed, signed, and dated by each client and/or their responsible party and that all of the remaining required documentation is present in all staff files to CCL by POC due date 12/23//2024.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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