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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490104577
Report Date: 02/15/2022
Date Signed: 02/16/2022 09:36:13 AM

Document Has Been Signed on 02/16/2022 09:36 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:SENIOR DAY PROGRAMFACILITY NUMBER:
490104577
ADMINISTRATOR:CIMINO, MONTEFACILITY TYPE:
775
ADDRESS:25 HOWARD STREETTELEPHONE:
(707) 765-8490
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 20CENSUS: 0DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Monte Cimino - AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by staff who contacted administrator. Administrator Monte Cimino arrived during the visit. There were no clients present at the facility today. Facility has 7 clients enrolled in the program at this time. Facility has different activities been offered through out of the day.

LPA toured the facility on 2/15/2022 with administrator Monte Cimino. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPA toured building and grounds, day activity rooms, kitchen, and bathrooms. Smoke detectors and Carbon monoxide were tested and are properly operating. Fire extinguishers are fully charged with last inspection on 11/2021. Clients have their own transportation. Facility does not transport clients at this time. Toxins, chemicals and hazardous items were safely stored in a locked cabinet under the kitchen sink. Bathrooms were all equipped with soap dispensers and individual paper towels. Hot water temperature measured between 111.0 degrees F and 114.5 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in bathrooms. Clients provide their own snacks and lunches, but program will supply food for special occasions. There is one refrigerator available for client food. Facility doesn’t administer medications or handles P&I.

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Some posters have been placed at entrance. Facility has hand sanitizer available for visitors, staff, and clients. Staff before coming into work have temperature checked.

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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: SENIOR DAY PROGRAM
FACILITY NUMBER: 490104577
VISIT DATE: 02/15/2022
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Facility has PPE supply stored in the facility office. There has not hired new staff and has new clients admitted since COVID. Clients wear masks most of the time when inside the facility per administrator. All staff had masks on during this visit. Staff have had all PPE training required on file and is working towards acquiring N-95 fit testing. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have not been conducted since facility has just reopened.

There were no deficiencies cited at this time.

Department is requesting facility to submit the following update documents by 2/12/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
LIC809 (FAS) - (06/04)
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