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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803783
Report Date: 11/12/2024
Date Signed: 11/12/2024 12:30:15 PM

Document Has Been Signed on 11/12/2024 12:30 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 BAYFACILITY NUMBER:
486803783
ADMINISTRATOR/
DIRECTOR:
BRIANA TERRELLFACILITY TYPE:
775
ADDRESS:5100 FULTON DRTELEPHONE:
(707) 430-4380
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 90CENSUS: 67DATE:
11/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:28 AM
MET WITH:Briana Terrell (Administrator)TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Required Annual inspection and met with Briana Terrell (Administrator). Annual fees are current. Participants were participating in a variety of activities at the time of visit. Facility was compliant with the ratio dictated by the regional center.

The facility was toured at 9:45am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Participants bring their own snacks and lunches which are stored in the refrigerator. Bathrooms had hand rails for safety and appeared sanitary. Water temperature read at 118.8 and 113.9 F which are within regulation of 105 and 120 degrees Fahrenheit. Cleaning supplies and chemicals are located in a locked cabinet. Transportation is provided through R & D. Vehicles are maintained by vendor. The facility is on a central fire/smoke alarm system and sprinkler system, which were inspected by the Fire Department on August 12, 2024. Fire extinguishers are located throughout the facility and were last serviced on May, 2024. There are multiple first aid kits located on both floors of the program. Last Emergency Disaster Drill was conducted on October 17, 2024. Required postings observed.

LPA initiated a file review of five staff and ten participant files at approximately 10:00 am. One out of five staff (S1) do not have First Aid/CPR Certificates, the facility had records on file of online CPR/1st aid training. LPA have a conversation with administrator about the difference between online training and in-person training (technical advisory was issued). All participants' files have medical assessments and care plans updated. Facility does not handle medications or cash resources. The facility will submit updated copies of the following by 11/22/24: Designation of facility responsibility (LIC308), personnel report (LIC500), Emergency disaster plan (LIC610D if there are any changes) and lease agreement.

No deficiencies cited during today's visit. Exit interview was conducted with Administrator and copy of this report was provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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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