<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803783
Report Date: 09/09/2021
Date Signed: 09/09/2021 02:08:32 PM

Document Has Been Signed on 09/09/2021 02:08 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, 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Shane Clarkson, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Lopez conducted an unannounced case management inspection and met with Administrator, Shane Clarkson. During facility's annual required infection control inspection on 9/9/21 facility disclosed that they had recently submitted an incident report regarding participant (P1's) inappropriate behavior with (P2) on 8/27/21. LPA consulted with facility submitting SOC341 in regards to these type of incidents and Administrator, Shane Clarkson completed SOC341 during visit. LPA received physical report. LPA Lopez requested documents and took statements from Administrator, Shane Clarkson and P2. LPA will review information.

No deficiencies cited during this 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)
Page: 1 of 1