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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803783
Report Date: 10/20/2022
Date Signed: 10/20/2022 10:26:27 AM

Document Has Been Signed on 10/20/2022 10:26 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: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: 38DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Program Manager, Shane ClarksonTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at United Cerebral Palsy of the North Bay for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Program Manager, Shane Clarkson, and was granted access into the facility.

LPA toured the facility with the Program Manager. Facility is a two floor building. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Hot water temperature measured at 107 degrees F in 5 of 5 client bathrooms. Smoke Detector and Carbon Monoxide Detector sound directly to the fire station and were last tested on August 2022. Emergency Disaster Drill was conducted on September 14, 2022. Fire extinguisher was last inspected and charged on May 2022. First Aid kits were observed and appropriate during the inspection. The facility has a phone line designated for client use. There is a supply of personal hygiene products located with the PPE storage. Personnel records and client records are stored at the facility office area. The first level floor includes two kitchens equipped with refrigerators. Art, drawing & painting room, conference room, activity rooms, storage, offices and client's & staff bathrooms are also located on the second floor. Activities are pre-planned and reflect on the Activity Board. Client, staff records and toxins are locked and inaccessible to clients in care. Clients will bring their own food and food will be provided for plan celebrations. Limited Use, Limited Access elevator that transports clients from the first floor to the second floor was installed with a permit issued by State of California-Division of Occupational Health and Safety on August 17, 2022 (Elevator # 185989). Motor vehicle to be used to transport clients inspected to ensure safe operating condition and will be offered if needed.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE located in and around the facility for use. Facility also has PPE stored in the second floor and the Program Managers office. (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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: UNITED CEREBRAL PALSY OF THE NORTH BAY
FACILITY NUMBER: 486803783
VISIT DATE: 10/20/2022
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LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was given to the facility Program Manager, Shane Clarkson.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC809 (FAS) - (06/04)
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