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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803783
Report Date: 10/09/2025
Date Signed: 10/09/2025 02:17:12 PM

Document Has Been Signed on 10/09/2025 02:17 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
SANTA ROSA RO, 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: 66DATE:
10/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Administator, Briana TerrellTIME VISIT/
INSPECTION COMPLETED:
02:49 PM
NARRATIVE
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On 10/09/2025 at approximately 9:25AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct a Required 1 Year visit and met with Administrator, Briana Terrell. Facility is an Adult Day Program for Adults with Disabilities. Facility has an approved fire clearance and capacity for 90 Clients, of which 9 Clients can be non-ambulatory. Upon arrival, LPA was informed that there were 66 clients attending Day Program and 26 staff members on-site. Facility is a two-story building with 5 classrooms, 4 bathrooms, 5 staff offices, library room and common areas. Facility provides mostly in-person services, Monday through Friday from 9:00 AM - 3:00 PM. Participants were participating in a variety of activities at the time of visit.

At approximately 10:15AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 10:45AM, LPA and Program Director toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. LPA observed activity supplies for resident use. Chemicals and other items which could pose a risk to clients in care stored in locked metal cabinets and closets. Soap & paper towels were available in facility bathrooms. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Water temperature measured 108.6 degrees F and 113.2 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire extinguishers were charged and were last serviced 6/2025.

Facility is hardwired with a fire sprinkler system which was failed in the last annual inspection and report was indicating new parts need to be ordered (See LIC809-D Page). Administrator agrees to submit new inspection results once the issue fixed. There was enough lighting in all common areas and hallways.
Continued in LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2025
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/09/2025 02:17 PM - It Cannot Be Edited


Created By: Ali Deniz On 10/09/2025 at 01:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: UNITED CEREBRAL PALSY OF THE NORTH BAY
FACILITY NUMBER: 486803783

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above, the facility is hardwired with a fire sprinkler system which was failed in the last annual inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Administrator agrees to submit the updated fire inspection report once facility passed the test to CCL by Plan of Correction due date 10/29/2025
Type B
Section Cited
CCR
82068.2(f)(1)(B)
Needs and Services Plan
(f) The completed Needs and Services Plan shall include: (1) The client's desires and background and formal supports, obtained from the client's family or his/her authorized representative, if any, regarding the following: (B) A written medical assessment including primary physician, health problems and medical history, prescribed medications and their strength, quantity, frequency required and purpose as specified in Section 82069(b)(3).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 7 clients did not have Medical Assessments on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Administrator agrees to submit the Medical Assesments for those two clients once they are completed to CCL by Plan of Correction due date 10/29/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Ali Deniz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/09/2025 02:17 PM - It Cannot Be Edited


Created By: Ali Deniz On 10/09/2025 at 01:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: UNITED CEREBRAL PALSY OF THE NORTH BAY
FACILITY NUMBER: 486803783

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(b)(1)
Client Medical Assessments
(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in2 out of 7 clients did not have TB results on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Administrator agrees to submit the TB results for those two clients once they are completed to CCL by Plan of Correction due date 10/29/2025
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Ali Deniz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: UNITED CEREBRAL PALSY OF THE NORTH BAY
FACILITY NUMBER: 486803783
VISIT DATE: 10/09/2025
NARRATIVE
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Continued from LIC809...

At approximately 12PM, LPA reviewed 7 clients records and found 7 of 7 clients have current care plans on file. 2 out of 7 clients did not have Medical Assessments on file (See LIC809-D page). 1 out of 7 files did not have signed admission agreement on file (Technical Violation Given). 2 out of 7 clients did not have TB results on file. (See LIC809-D page).

LPA reviewed 4 staff records. Staff records did contain documentation of completed training records, health screening as required. Evidence of current first aid and CPR training were current. 2 out of 4 staff members had renewal first aid and CPR training scheduled for 10/14/2025 and 10/17/2025 (Technical Advise Given).
Facility has an Infection Control plan on file. Facility conducted and documented a disaster drill on 07/11/2025.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 10/20/2025:

LIC 308 Designation of Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If changed)
LIC 9020 Register of Facility Client’s/Resident’s
Copy/Proof of Updated Certificate of Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC809 (FAS) - (06/04)
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