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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803638
Report Date: 05/03/2024
Date Signed: 05/03/2024 11:43:47 AM

Document Has Been Signed on 05/03/2024 11:43 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:SOLANO DIVERSIFIED SERVICESFACILITY NUMBER:
486803638
ADMINISTRATOR/
DIRECTOR:		CHIOFALO, LOUISFACILITY TYPE:
775
ADDRESS:1234 EMPIRE STREET 1401-1412TELEPHONE:
(707) 552-9443
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 30CENSUS: 18DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Marcelle McKinley, Program CoordinatorTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On 5/3/2024 Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr inspection for this facility and met with Program Coordinator, Marcelle McKinley. The facility currently provides care for 18 clients, 13 of which were at the facility at the time of visit. The facility is currently conducting full in-person service program with alternative online services available to clients.

LPA continued with a tour of the facility with Coordinator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire extinguishers were found to be last charged December 2021, however the facility had received a fire safety inspection within the year. LPA attempted to contact Fairfield Fire Marshal for confirmation but was unsuccessful. LPA requested for copy of fire inspection results from the Program Coordinator for review. Maintenance and daily logs are also documented on file. Lastly, emergency disaster drills are conducted on both a monthly and quarterly basis. LPA conducted an inspection of 2 out of 2 facility vans and found all vans to be properly equipped with fire extinguisher and 1st aid kits. Toxins, cleaning supplies and other potentially dangerous items are to be stored in a designated cleaning supply closet inaccessible to clients.

Clients were observed to be engaged in various group activities, using electronic media devices, and other options to choose during program hours. Additional outings include visits to public parks and shopping center. Facility designates several Direct Support Staff to accompany clients by group. Staffing was found to be sufficient. Clients observed to have positive relationship with staff continuously engaging and participating with clients. LPA was informed that clients currently provide their own meals with snacks provided throughout the day. Facility primarily holds outdoor activities during outings at local public parks.

Continue onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SOLANO DIVERSIFIED SERVICES
FACILITY NUMBER: 486803638
VISIT DATE: 05/03/2024
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The facility does not handle either client cash resources or medications within the program. LPA conducted a file review of client records and found all items including, individual service plans and physician's report to be in order. In addition, LPA conducted a file review of staff records and found staff to have sufficient amount of annual training and CPR & 1st Aid training completed.

LPA requested the following documents be sent to CCL by COB 6/3/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Fire Inspection Report

No deficiencies cited.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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