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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804199
Report Date: 01/23/2025
Date Signed: 01/27/2025 08:34:35 AM

Document Has Been Signed on 01/27/2025 08:34 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:EQUIVENTURE ACTIVITY CENTERFACILITY NUMBER:
486804199
ADMINISTRATOR/
DIRECTOR:		DINGLASAN, CYNTHIAFACILITY TYPE:
775
ADDRESS:1 HARBOR CENTERTELEPHONE:
(510) 421-4182
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 60CENSUS: 25DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Cynthia Dinglasan, Director & Program Manager, Joselito "Joey" RemoTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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At approximately 9:45 AM, Licensing Program Analysts (LPAs) Julie Florio and Star Stevenson arrived unannounced to conduct a Required - 1 Year inspection and met with Director Cynthia Dinglasan. Facility provides mostly in-person services, Monday through Friday from 8:00 AM - 3:00 PM. The facility offers Zoom participation for clients who wish to attend from home. Facility has transportation services available (4 vans) via R & D Transport. Facility is vendorized with North Bay Regional Center (NBRC) and all the clients have a service coordinator.

At approximately 10:30 AM LPAs initiated tour of the facility and observed the following: facility was clean, orderly, and was a comfortable temperature. Facility has all the required signage posted. Exits were observed unobstructed and chemicals and other items which could pose a risk to clients in care were observed stored in locked cabinets and closets. Hygiene and paper products were available to clients. Water temperatures in facility bathrooms tested within the allowable range of 105-120 degrees Fahrenheit per Title XXII regulations. "Caution hot water" signs were posted above sinks. LPAs observed multiple first aid kits, PPE, emergency supplies, incontinent care products, and water. Fire extinguishers were both observed fully charged and last inspected 1/23/2025. Facility is hardwired with a sprinkler system which was last inspected 10/2024. Director informed LPAs that fire department is due to come out and perform annual inspection and contacted the local fire marshal to schedule during today's visit. Facility conducts emergency disaster drills semi-annually with the last drill conducted 11/07/2024. LPAs informed Director that disaster drills shall be conducted quarterly to remain in compliance with regulation. Director agreed to ensure the facility is in compliance moving forward. Facility has large changing rooms with four (4) electric beds, two (2) ceiling rail lifts, and has one mobile hoyer lift.

LPAs observed a number of activities available to clients including touch screen computers with life skills, language, and other educational software for clients. Additionally, LPAs observed activities which facilitate activities of daily living and self care management, as well as arts/crafts, a piano and other musical instruments, bowling, video games, a theater room, massage chairs facing marina, sensory station, karaoke, social time, 1-on-1 activity room with pads on floor, quiet room, games, and more.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: EQUIVENTURE ACTIVITY CENTER
FACILITY NUMBER: 486804199
VISIT DATE: 01/23/2025
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Medications were observed centrally stored and locked per regulation. Facility has two (2) RNs that administer G-tube feedings to clients requiring such care. Facility does not handle client cash resources.

At approximately 11:30 AM, LPAs initiated file review of seven (7) staff and seven (7) client files. Four (4) of seven (7) staff files reviewed were missing one (1) or more of the required documents including proof of first aid training as required per regulation, (see LIC 809D). Three (3) of seven (7) client files reviewed were missing one (1) or more of the required documents per regulation, (see LIC809D).

At approximately 3:30 PM, Director had to leave for an appointment, and gave permission to review report with Program Manager, Joselito "Joey" Remo.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 - Personnel Report (updated)
  • LiC610 - Emergency plan (updated)

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, 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 with Program Manager, whose signature on form confirms receipt of documents. Appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/27/2025 08:34 AM - It Cannot Be Edited


Created By: Julie Florio On 01/23/2025 at 01:25 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: EQUIVENTURE ACTIVITY CENTER
FACILITY NUMBER: 486804199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 7 staff records reviewed, missing 1 or more of the required documents per regulation, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
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Licensee to submit proof of negative TB for (S1) and (S3), proof of 1st aid training for (S2, S3, S4) and completed and signed medical assessment for S3 to CCL by POC due date 02/24/2025.
Type B
Section Cited
CCR
82070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. A separate, complete, and current record shall be maintained at the program site for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 7 client records reviewed, missing 1 or more of the required documents per regulation, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
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Licensee to submit proof of negative TB for C1 and C2, the emergency contact and LIC602 for C2 and signed and dated consent for emergency treatment for C3 to CCL by POC due date 02/24/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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