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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803113
Report Date: 07/27/2022
Date Signed: 07/27/2022 02:50:08 PM

Document Has Been Signed on 07/27/2022 02:50 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:DUNGARVIN CALIFORNIA - ROHNERT PARKFACILITY NUMBER:
496803113
ADMINISTRATOR:DAVIS, SHANNONFACILITY TYPE:
775
ADDRESS:125 SOUTHWEST BLVDTELEPHONE:
(707) 664-8000
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 45CENSUS: DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Dominic Ordaz-Program DirectorTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) arrived unannounced to conduct a Required 1 Year inspection and met with Program Director Dominic Ordaz, and Shannon Davis, NCA Day Program's Manager. The inspection is focused on the Infection Control procedures and practices of this facility.

The Infection Control Plan was recently submitted by the facility as required. Facility is operating two sessions a week; One session is Monday and Tuesday and the second session is Thursday and Friday. Approximately, about 24 on-site clients enrolled and the rest are virtual day program participants.

Fire extinguishers (4) are scheduled for service and re-tagging-expires 8/25/22. Per Shannon the fire extinguishers will be serviced soon as required. There are nine vehicle fire extinguishers that are scheduled for service as well.

All staff, clients, and visitors are screened before being allowed to remain in the facility. All screenings, including screening questions and temperatures taken, all information is logged.

The light in this bathroom was not bright but was observed to be a bit dark, giving off a light grey color. Shannon stated the bulbs seemed to be low wattage and agreed they were a bit dark, she will be replacing the bulbs. All other bathrooms checked had bright lights.

Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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: DUNGARVIN CALIFORNIA - ROHNERT PARK
FACILITY NUMBER: 496803113
VISIT DATE: 07/27/2022
NARRATIVE
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LPA discussed with Shannon the clients outside courtyard and ensuring to monitor the concrete flooring for any maintenance or repair if needed for clients use. Shannon stated she is working on having the courtyard area looked at for any needs to continue safety for the clients. All clients are supervised by staff when in the courtyard, per Shannon.

LPA discussed the facility and the deep cleaning /maintenance of the facility with Shannon Davis and Dominic Ordaz. Per Shannon, she has had meetings recently, regarding the facility's need for a deep cleaning, and is working on a plan for this. LPA observed that the facility's kitchen sink area was not very clean, counter space around the sink and the sink itself were dirty. LPA observed that under some of the furnishings and under the lockers around the facility there was dirt and LPA observed that it hadn't been cleaned under these items. LPA observed the shower room to have dirt around the rooms edges and the floor is not very clean. LPA observed in a bathroom the toilet to need cleaning around it, and observed the toilet to have no caulking around the bottom. Shannon stated that all bathrooms will be checked, cleaned appropriately as needed and caulking done if needed. This deficiency will be cited, Buildings and grounds 82087(a)-see LIC809D.

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.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/27/2022 02:50 PM - It Cannot Be Edited


Created By: Dina Alviso On 07/27/2022 at 12:14 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: DUNGARVIN CALIFORNIA - ROHNERT PARK
FACILITY NUMBER: 496803113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2022
Section Cited

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Buildings and Grounds 82087(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement was not met as observed by the LPA during the tour of the facility.
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LPA observed that the floor in the shower room was dirty and blackened areas in the corners of the room. The kitchen sink and counter area was dirty, the sink has not been cleaned for awhile by the looks of it. LPA observed that under some furnishings and under some lockers there was dirt and it has not been cleaned for awhile. LPA observed a bathroom that needed cleaning around the bottom and it had no caulking around it. Per Shannon she is working to get a deep cleaning done at the facility and will ensure all gets cleaned appropriately as required. This is a potential health and safety risk to clients' in care.
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Submit the plan of correction by 8/3/2022. You may also include pictures with your plan of correction and maintenance. POC due 8/3/2022.

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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
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