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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804199
Report Date: 02/14/2024
Date Signed: 02/14/2024 10:58:10 AM

Document Has Been Signed on 02/14/2024 10:58 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:EQUIVENTURE ACTIVITY CENTERFACILITY NUMBER:
486804199
ADMINISTRATOR:DINGLASAN, CYNTHIAFACILITY TYPE:
775
ADDRESS:1 HARBOR CENTERTELEPHONE:
(510) 421-4182
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 60CENSUS: 0DATE:
02/14/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Leonila Bunyi, Licensee ApplicantTIME COMPLETED:
11:15 AM
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On 2/14/2024 Licensing Program Analyst (LPA) Tobola conducted a pre-licensing inspection and was greeted by Licensee Applicant, Leonila Bunyi. Partnered Licensee Applicant, Cynthia Dinglasan is aware of the visit but unable to attend initial meeting due to scheduling conflict. This pre-licensing inspection is being conducted for an initial licensing. The day program facility is a single story lower unit in a multipurpose building with a granted fire clearance approved for 60 non-ambulatory clients.

LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean and comfortable temperature with all exit doors free from obstruction. Fire extinguishers located throughout the facility were found to be last charged on 11/3/2023. Smoke detectors and carbon monoxide detectors are interconnected for the entire unit and building. The facility was inspected by Suisun City Fire Marshall on 11/18/2023. LPA requested for Licensee Applicant to contact the Suisun City Fire Marshall for documentation on inspected smoke and carbon monoxide detectors. LPA unable to test due to interconnection throughout the building. There are three primary emergency exits accessible from each common area for clients and staff offices, all of which were found to be unobstructed. Water was measured between 119.2 and 119.6 degrees F in faucets used by clients which is within regulation between 105 & 120 degrees F.

There was an ample supply of hygiene, continence and paper products and are located in a designated supply room. Cleaning products and other toxins and chemicals are kept out of client access and are also located in the supply room but stored in a locked cabinet. Clients will be bring their personal lunches to the program. The facility will also have snacks and other smaller food items available for clients based on preferences and dietary restrictions. A sample menu is also in the program plan and kitchen area, indicating a healthy and balance set of food options for clients.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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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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: EQUIVENTURE ACTIVITY CENTER
FACILITY NUMBER: 486804199
VISIT DATE: 02/14/2024
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Medications are centrally stored and secured in locked carts located in the nurse office with Centrally Stored Medication Records and several other medication related forms ready for file. All staffing records and client specified files including care plans, medical reports and dietary restrictions will be stored in the staff offices.

Program Design and emergency disaster plan are located in the facility program file. Evacuation maps and licensing form templates pertaining to resident and staff rights have also been posted throughout the facility. The facility will be equipped with four vans for client transportation for outings and emergency purposes and will be vendored by R&D Transportation Services upon licensing. Relocation cites have been designated in the Suisun City area. LPA requested to include an additional evacuation cite located in a different city in case of wider evacuation.

The facility will be utilizing the large outdoor marina area towards the rear of the facility for client activities and leisure. The facility is equipped with a variety of activity supplies, sensory room, computer room and several other activity spaces for client engagement. Windows and blinds are all found to be in good repair. Infection control plan and protocol infection prevention information have been completed and submitted. A sign in sheet with proper screening devices and protection equipment were also observed at the facility front desk. The facility and facility operation plan are found to be adequate and tour of the facility completed.

The Licensee Applicant is to provide the following items:
- Documentation for inspected/cleared smoke and carbon monoxide detectors from Suisun Fire Marshall
All items to be submitted to CCLD by POC date 2/21/2024

Component III orientation was conducted with the Licensee Applicant. The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager. This report was reviewed with applicant and a copy was provided to the Licensee.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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