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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803735
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:12:24 PM

Document Has Been Signed on 04/18/2024 02:12 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/
DIRECTOR:		DINGLASAN, CYNTHIAFACILITY TYPE:
775
ADDRESS:258 SUNSET AVE. STE. MTELEPHONE:
(707) 759-3888
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 45CENSUS: 45DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:
Orlanditto Ordanez, Lead Staff & Cynthia Dinglasan, Licensee		TIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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On 4/18/2024 Licensing Program Analysts (LPAs) Tobola and Matialu conducted an unannounced Annual Required – 1 yr inspection for this facility and met with Program Manager, Orlanditto Ordanez. Licensee, Cynthia Dinglasan was contacted later in the visit. The facility currently provides care for 45 clients, 40 of which were at the facility at the time of visit. The facility is currently conducting full in-person service program with transportation contracted with R&D Services.

LPA continued with a tour of the facility with Director; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. 4 out of 4 fire extinguishers within the facility were found to be last charged April 16, 2024. Smoke and carbon monoxide detectors located in main common areas are interconnected. LPA was informed that an outside agency had conducted a fire inspection in October 2023 and had inspected safety devices including sprinkler system, alarms smoke and carbon monoxide detectors. Program Director to provide LPA with a copy of the fire inspection report. LPA's conducted an inspection of 6 out of 6 facility vans and found all vans to be properly equipped with fire extinguisher and 1st aid kits. Fire extinguishers were found to be last charged April 17, 2024. Lastly, emergency disaster drills are conducted on a quarterly basis and documented.

Toxins, cleaning supplies and other potentially dangerous items are to be stored in a designated cleaning supply closets inaccessible to clients. During inspection, LPA's observed 2 knives and several lighters located in the staff kitchen area away from clients. Items were immediately placed in secured area. In addition, facility agrees to install secured locks on staff kitchen drawers for added safety measures.

Clients were observed to be engaged in various group activities both indoor and outdoor patio including, large group singing, arts & crafts, one-on-one classes, 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 and also has a large outdoor parking lot area located on the rear of the building for client use.

Continue onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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: EQUIVENTURE DAY PROGRAM
FACILITY NUMBER: 486803735
VISIT DATE: 04/18/2024
NARRATIVE
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Water temperature at faucets accessible to clients measured between 110.0 and 125.0 degrees F which is not within Title 22 regulations requiring water measurements between 105 and 120 degrees F. Water temperature measurements fluctuated depending on location within the building, with the water heater shared amongst several other businesses. Staff ensure each client is provided hands on assistance with hand-washing protocols. Licensee agrees to place proper signage indicating water temperature levels may exceed 125 degrees F. Technical Advisory issued. Upon a spot check of medications, LPA's found that 1 out of 1 medications for client (C1) was removed from it's original container 2 hours before prescribed administering. Licensee agrees to continue protocols of live medication administration moving forward. Technical Violation issued. LPA conducted a file review of client records and found all items including, individual service plans and physician's report to be in order. LPA conducted sample file review of staff records and found staff to have sufficient annual training and CPR & 1st Aid training completed.

Upon a review of the Guardian Background Check roster, LPA's found that 1 staff (S1) was not properly associated to the facility. LPA's ensured that staff S1 was requested to immediately leave the premise and that S1 is not to be on site until fingerprint clearance and association is completed. A civil penalty was issued for a total amount of $500 for staff (S1) for not having a proper Criminal Background Clearance prior to working in the facility.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

LPA requested the following documents be sent to CCL by COB 5/18/2024:

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
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/18/2024 02:12 PM - It Cannot Be Edited


Created By: Dominic Tobola On 04/18/2024 at 01:33 PM
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: EQUIVENTURE DAY PROGRAM
FACILITY NUMBER: 486803735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff not properly associated with fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee has ensured staff S1 was escorted out of the facility and will be completing fingerprint clearance and association before returning to the facility. Deficiency cleared at time of visit. In addition, Licensee to provide fingerprint determination by POC due date 5/2/2024. A civil penalty was issued for a total amount of $500 for staff (S1) for not having a proper Criminal Background Clearance prior to working in the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/18/2024 02:12 PM - It Cannot Be Edited


Created By: Dominic Tobola On 04/18/2024 at 01:33 PM
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: EQUIVENTURE DAY PROGRAM
FACILITY NUMBER: 486803735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 knives and several lighters that located unsecured in staff kitchen area which poses/posed a potential health, safety risk to persons in care. In addition, licensee agrees to contact building management for pest control services.
POC Due Date: 04/25/2024
Plan of Correction
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Licensee immediately removed items from staff kitchen area and placed in secured closet. In addition, Licensee agrees to submit photo corrections of locks/magnets installed in staff kitchen drawers by POC date 4/25/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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