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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804044
Report Date: 03/04/2022
Date Signed: 03/04/2022 11:51:53 AM

Document Has Been Signed on 03/04/2022 11:51 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:KREATIVE COMMUNITY SERVICES - BLOOMFACILITY NUMBER:
486804044
ADMINISTRATOR:ALOE, SHAYNEFACILITY TYPE:
775
ADDRESS:1241 ALAMO DRIVE SUITE 7TELEPHONE:
(707) 474-9653
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 60CENSUS: 17DATE:
03/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Shayne Aloe, LicenseeTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced pre-licensing inspection for a change of ownership (CHOW), and met with Applicant, Shayne Aloe who will be the Licensee/Administrator once the facility is approved for licensure.

The facility has a fire clearance approval from the Vacaville Fire Department for 60 non-ambulatory clients. Facility is offering in person, and alternative services. Facility will operate 5 days a week, 9 AM to 3 PM.

At approximately 9:10 AM, LPA toured the facility with Shayne Aloe, Program Managers, Danielle Guisande, and Sara Irwin. LPA made the following observations: Signs were posted on the exterior of the facility to inform visitors of their visiting policies. At both the visitor and staff entrances there were carts stocked with hand sanitizer, N95 Mask, surgical mask and thermometers. Staff utilize an application on I PADs to screen visitors for COVID symptoms.


Report continued on 809 C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
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: KREATIVE COMMUNITY SERVICES - BLOOM
FACILITY NUMBER: 486804044
VISIT DATE: 03/04/2022
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Continued 809

At the time of the inspection there were 9 clients attending day programs. Clients arrived using transportation services, and were screened for COVID-19 symptoms prior to arriving at the facility. Clients were separated into 5 activity rooms: Game room, fitness, art, media and behavioral room. Rooms were observed to be clean and organized. Each room had gloves and hand sanitizing stations. Bathrooms were stocked with hand washing supplies and paper products. Cleaning Schedules are posted in the facility hallways, with the staff assignment.

All exits were free from obstructions. Toxins/cleaners and sharps were stored in a locked closet. Facility has a locked medication cabinets in two separate areas of the facility. First Aid Kits were complete with all required items. Hard wired smoke alarms and fire sprinklers were last inspected by Vacaville Fire Department. Carbon monoxide detectors were tested and appeared to be operational. Fire Extinguishers were last inspected 1/14/22. The water temperature was tested during inspection and was within regulation of 105-120 Degrees F.

LPA reviewed staff and client records. Facility has all records as required per regulation. Client and staff vaccination records are stored in their appropriate file. Staff have received required training as required. Staff on shift have CPR and first aid training.

Pre-licensing is complete and this facility has no deficiencies.

The Component III Orientation was completed with applicant during this visit.

LPA will submit the pre-licensing application report to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC809 (FAS) - (06/04)
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