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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804166
Report Date: 09/18/2023
Date Signed: 09/18/2023 05:22:51 PM

Document Has Been Signed on 09/18/2023 05:22 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:REM SENIOR DAY PROGRAMFACILITY NUMBER:
486804166
ADMINISTRATOR:FELIX, MARYFACILITY TYPE:
775
ADDRESS:3777 VACA VELLEY PKYTELEPHONE:
(707) 640-9700
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 40CENSUS: 0DATE:
09/18/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Mary Felix, AdministratorTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived announced at REM Day Program for the purpose of conducting a Pre-Licensing inspection. LPA was greeted at the door by Administrator, Mary Felix and was granted access into the facility. Facility is approved for 40 clients which was granted Fire Clearance on 07/06/2023. Mary Felix received Administrator Certificate, # 6033609740, which expires on 01/22/25.

LPA and Administrator toured the facility. Facility is one story with ample space for activities and socialization. There are 2 restrooms for staff and clients, which are equipped with soap and paper towels, and grab bars in each stall. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers are dated for 07/03/2023 and are fully charged. Carbon monoxide detector was tested and operational. Sprinkler system is hardwired and signals directly to the fire station. A sample Activities Calendar was reviewed during the inspection and found to be appropriate. Resident records, personnel records, medication will be locked in storage cabinet, toxins are kept locked in another storage cabinet. Facility has first aid kit which was inspected and found to be appropriate during the Pre-Licensing inspection. There is outdoor space for activities. There is a room set aside for a Sensory Room, there is a karaoke machine, lounging area, arts and crafts, tables and chairs for eating and socializing, and a large space for exercise and large motor activities. The kitchen is clean and well-organized and supplied with drinks and snacks. Clients will be providing their own lunches. There is an adequate supply of emergency supplies.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023
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: REM SENIOR DAY PROGRAM
FACILITY NUMBER: 486804166
VISIT DATE: 09/18/2023
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Continued.....

LPA conducted a COMP III with applicant. Some of the following items were discussed: Administrator Qualifications, Reporting Requirements, Clients behaviors and Personal RIghts, Personal Accommodations, Criminal Background Clearance, Acceptance and Retention, Guardian, Restrictedand Prohibited Health Care Conditions.

This pre-licensing is complete. LPA will submit the pre-licensing reports to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. A copy of the report was given to the Applicant.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC809 (FAS) - (06/04)
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