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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803735
Report Date: 05/11/2023
Date Signed: 05/11/2023 12:12:14 PM

Document Has Been Signed on 05/11/2023 12:12 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:EQUIVENTURE DAY PROGRAMFACILITY NUMBER:
486803735
ADMINISTRATOR:DINGLASAN, CYNTHIAFACILITY TYPE:
775
ADDRESS:258 SUNSET AVE. STE. MTELEPHONE:
(707) 759-3888
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 45CENSUS: DATE:
05/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Cynthia Dinglasan. DirectorTIME COMPLETED:
12:25 PM
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On 5/11/2023 Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr inspection for this facility and met with Program Director, Cynthia Dinglasan. The facility is licensed by Equiventure Day Program Inc. and currently serves 44 clients, 41 of which were at the facility at the time of visit. The facility is currently conducting full in-person service program with hybrid options available to some clients.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with staff; 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 March 3, 2023. Suisun City Fire Department conducted fire safety inspection on 9/6/2022 for all exits, safety devices including sprinklers, alarms and smoke and carbon monoxide detectors.

Clients are non-ambulatory and appear to be engaged in various group activities including, roll call, dancing, exercise, crafts and other options to choose from. Facility designates several Direct Support Staff to accompany clients by group. 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 continues to hold outdoor activities in the courtyard, surrounding shopping area or public parks with staff providing transportation. Toxins, cleaning supplies and other potentially dangerous items are stored in a designated cleaning supply closet inaccessible to clients. Facility has contracted with R&D Transportation Services who conduct symptom and temperature checks upon picking up clients and entrance into the facility.


Continue onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2023
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: EQUIVENTURE DAY PROGRAM
FACILITY NUMBER: 486803735
VISIT DATE: 05/11/2023
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Water temperature at faucets accessible to clients measured between 108.6 and 116.6 degrees F which is within Title 22 regulations requiring water measurements between 105 and 120 degrees F. Staff provided direct support in client hygiene and continence care, observing clients on change of condition every hour as needed. Spot medication review was conducted and found to be in order. On-site licensed RN and LVN staff are responsible for medication administration and injections. Facility is provided physician's orders indicating instructions and fill dates for prescribed medications. Medication is not stored on site. Facility utilizes Medication Administration Records for dosage count. LPA conducted sample file review of staff records and found all staff to have sufficient training and CPR & 1st Aid certification on file. In addition, LPA reviewed 5 out of 5 client files and found documentation to be in order.

Facility will be submitting an updated Infection Control Plan for review. Posters are located at the facility entrance, common areas and each classroom indicating COVID protocols and mitigation. Facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for clients and staff. Staff and clients are also screened on a daily basis.

LPA requested the following documents be sent to CCL by COB 5/25/2023:

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

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC809 (FAS) - (06/04)
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