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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490104577
Report Date: 01/30/2023
Date Signed: 01/30/2023 02:43:43 PM

Document Has Been Signed on 01/30/2023 02:43 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:SENIOR DAY PROGRAMFACILITY NUMBER:
490104577
ADMINISTRATOR:CIMINO, MONTEFACILITY TYPE:
775
ADDRESS:25 HOWARD STREETTELEPHONE:
(707) 765-8490
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 20CENSUS: 8DATE:
01/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Elece Hempel (Executive Director)TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Executive Director, Elece Hempel. The inspection is focused on the Infection Control procedures and practices of this facility. The program is open on Mondays, Wednesdays and Fridays from 10am to 2pm.

There are 2 common bathrooms available for participant use. Facility has posters through the building and have a centralized sign-in location. Facility screens all participants, visitors and staff upon arrival and sign them in. The facility consists of a large area for participants use. Facility has sufficient personal protective equipment for staff and participants including gloves, hand sanitizer and masks. All bathrooms and surfaces in the facility are sanitized at least once per day, participants have the option of eating at the on-site dinning area. LPA observed that staff were wearing masks during this visit, meals are provided pre-packaged meals by Meals on Wheels. Facility has requested that participants or their responsible parties check the temperature of participants each morning. Facility does not provide transportation services. If a participant is exhibiting symptoms, they are to stay home and notify the facility. Facility has submitted and approved their Mitigation Plan on 8/19/21. Staff have incorporated training on infection control and donning and doffing of Personal Protective Equipment (PPE) into their regular training schedule. Facility is located in a building and the fire system is monitored and maintained by the landlord who is the City of Petaluma.

Executive Director and LPA discussed the importance to have a designated person on file (LIC308) as a backup Administrator, Emergency Disaster Plan, Mitigation Plan and Infection Control Plan.

No deficiencies cited during this inspection. Exit interview was conducted with Executive Director and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
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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