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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490102164
Report Date: 01/22/2024
Date Signed: 01/22/2024 12:31:17 PM

Document Has Been Signed on 01/22/2024 12:31 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:SEBASTOPOL DAY SERVICESFACILITY NUMBER:
490102164
ADMINISTRATOR:DUFFY, REBECCA JFACILITY TYPE:
775
ADDRESS:167 NORTH HIGH STREETTELEPHONE:
(707) 525-0143
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 30CENSUS: 6DATE:
01/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Rebecca Duffy (Site Coordinator)TIME COMPLETED:
12:46 PM
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Licensing Program Analyst (LPA), Cuadra, arrived unannounced to conduct an Annual Required Inspection and met with Site Coordinator, Rebecca Duffy. The program is open to clients Mondays and Wednesdays from 10:00 am to 2:00 pm. Required postings were observed. Contact information needs to be updated.

LPA initiated a tour of the facility at 10:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Six participants were sitting at a table and were engage in activities like discussion about newspaper articles and games at the time of visit. The activity schedule for the day was written on a white board. The day program operates out of a primary room within the Sebastopol Senior Center and participants have the option of eating at the on-site dinning area. Meals are provided by Meals on Wheels. Program maintains a supply of coffee for snacks. There are 2 common bathrooms available for participant use and exterior space. Water temperature in bathroom measured at 93.7 degrees F which is not within allowable range of 105 to 120 degrees F. Technical violation will be issued. Bathrooms were equipped with grab bars to ensure safety. Toxins were inaccessible. Facility does not handle medications for day program participants and does not provide transportation. Fire extinguisher was last inspected July, 2023. The smoke alarm system and fire extinguishers are maintained by the Sebastopol Senior Center. The smoke alarm system is maintained by a vendor and the most recent test was completed in July, 2023. Most recent Fire/Disaster drill was conducted 12/6/2023. Carbon monoxide was operational.
LPA initiated file review at 11:00am. Two staff files and five participant files were reviewed. Staff have required First Aid and CPR certificates, but no annual training hours were on file. Participant's plan of care is conducted semi-annual were current. Participants medical assessment are updated. Administrator agreed to submit updates of the following documents by 1/29/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Lease agreement and Emergency Disaster Plan (LIC610E).
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and copy was provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2024
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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Document Has Been Signed on 01/22/2024 12:31 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 01/22/2024 at 12:17 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: SEBASTOPOL DAY SERVICES
FACILITY NUMBER: 490102164

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065.1(d)(1)
Personnel Qualifications and Duties
(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Administrator's observation, records review and interviews, the licensee did not comply with the section cited above in two out two staff (S1 & S2), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Facility will conduct required training hours with staff and will submit LIC9098 self-certification as proof of correction by POC due date.
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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024


LIC809 (FAS) - (06/04)
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