486803783-10-5-2023-21-AS-DTOA-CWBREB-20231005125716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803783
Report Date: 10/05/2023
Date Signed: 10/05/2023 12:57:23 PM

Document Has Been Signed on 10/05/2023 12:57 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:	UNITED CEREBRAL PALSY OF THE NORTH BAY		FACILITY NUMBER:	486803783
ADMINISTRATOR:	CLARKSON, SHANE		FACILITY TYPE:	775
ADDRESS:	5100 FULTON DR		TELEPHONE:	(707) 317-8559
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY: 90		CENSUS: 90	DATE:	10/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Saifon Bond Program Manager, & Sarah Wiggins, Assistant Program Coordinator		TIME COMPLETED:	01:15 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	On 10/5/2023 Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr inspection for this facility and met with Program Manager, Saifon Bond and Assistant Program Coordinator, Sarah Wiggins . The facility is licensed by The United Cerbral Palsy of the North Bay and currently serves 90 clients, 62 of which were attending in-person program at the time of visit. The facility is currently conducting in-person service program Monday through Friday with several clients provided online courses. 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 May 12, 2023. Fairfield Fire Department conducted fire safety inspection on February 2023 for all exits, safety devices including sprinklers, alarms and smoke and carbon monoxide detectors. Clients were observed to be engaged in various group activities including, discussion, arts & crafts, computer activities, a multi-staffed second-hand store item sorting operation and other options to choose during operation hours. In-person courses on resume building, job interviews, internet security, budgeting and home etiquette are also implemented for client transition to more independent living. During the visit, transportation staff and clients were observed preparing to go on outings including visits to local parks and shopping centers, food banks and lunch. Facility designates several Supervising Staff to accompany clients by group. The facility also offers a wide variety of scheduled events and trips throughout the year including camping, zoo and museum visits, and after hour socials and dances. Clients were observed to have positive relationship with staff, both of which were seen continuously engaging and participating in the program. LPA was informed that clients currently provide their own meals with snacks provided throughout the day with additional lunch items available for purchase in the dinning area. Facility also offers scheduled lunch outings scheduled throughout the month. Toxins, cleaning supplies and other potentially dangerous items are stored in a designated cleaning supply closets and containers located throughout the facility and secured. Continue onto LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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: UNITED CEREBRAL PALSY OF THE NORTH BAY	FACILITY NUMBER: 486803783
	VISIT DATE: 10/05/2023

NARRATIVE

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Facility has contracted with R&D Transportation Services with completed daily maintenance logs on file. A spot check of facility vans was conducted with vans found to be equipped with appropriate emergency supplies and first aid kit. During the tour LPA found elevator located in the warehouse/storage area in need of an updated servicing. Facility Operations Manager has contacted the contracted services and requested for an inspection as of 9/20/2023 with documented contact. The facility was informed of a delay on the inspection services but will follow up and determine a specific date or time frame for completion. Technical Advisory issued. Water temperature at faucets accessible to clients measured between 71.0 and 71.4 degrees F which is not within Title 22 regulations requiring water measurements between 105 and 120 degrees F. Facility agrees to complete a 7-day water temperature log and submit to CCLD once completed ensuring temperatures are within regulation. Technical Violation issued. LPA conducted a file review of client records and found all items including, program individual plans, personal rights and physician's report to be updated or in order. LPA conducted sample file review of staff records and found staff annual training and CPR & 1st Aid certification in need of reconciling. Facility has an in-service instructor for 1st Aid & CPR certification and completed training for all staff, however, documentation is currently being process at the facility main offices. Facility agrees to reconcile staff training and 1st Aid & CPR certification to reflect on-site program files. Facility to submit LIC9098 Proof of Corrections forms once completed.

Case Management:
LPA Tobola also conducted a Case Management visit for the purpose of following up on several self-reported incidents involving clients exposed to pepper spray in the facility. It was found that a pepper spray bottle was attached to a client's keychain and accessible to other clients in care. Facility staff have taken appropriate measures to ensure safety of clients moving forward including key checks, meeting with clients prohibiting pepper spray or any other items that could pose a threat into the facility, as well as an updated policy for clients to leave all personal belongings in their designated lockers and backpacks.

LPA requested the following documents be sent to CCL by COB 11/5/2023:
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: 10/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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