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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803783
Report Date: 09/09/2021
Date Signed: 09/09/2021 11:25:26 AM

Document Has Been Signed on 09/09/2021 11:25 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:UNITED CEREBRAL PALSY OF THE NORTH BAYFACILITY NUMBER:
486803783
ADMINISTRATOR:CLARKSON, SHANEFACILITY TYPE:
775
ADDRESS:5100 FULTON DRTELEPHONE:
(707) 317-8559
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 90CENSUS: 84DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Shane Clarkson, AdministratorTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Lopez arrived unannounced to conduct an Annual Required inspection and met with Shane Clarkson, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Day Program.

The facility is currently providing some in-person Day Program services for 29 clients who attend throughout the week, half days. All clients have the option to attend program virtually which are full days. They currently have 80 classes available for clients per week. Fire Extinguishers were found to be last charged on May 10, 2021.

Upon arrival, LPA observed a screening station at front entrance of facility which had hand sanitizer, a thermometer, and a sign-in sheet. Staff took LPA temperature when LPA arrived. Sign-in sheet had a section for visitors to document name, temperature and answer COVID-19 screening questionnaire. Staff are screened for COVID-19 (including temperature check) upon arrival to the facility and are also logged into a sign-in sheet. After visitors are screened they receive a name tag/sticker. LPA conducted a walk-through of the facility with Administrator and observed COVID-19 precaution postings. Staff clean the facility daily and high touched surfaces are disinfected more than twice a day. Facility also had distancing floor signs.

Facility staff have completed training on PPE use, infection prevention and will be taking donning and doffing training. The facility has a supply of PPE. Staff wore masks during today's visit. The facility has a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was approved by the California Department of Social Services.

Exit interview conducted with Shane Clarkson, whose signature on this document confirms receipt.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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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