496803113-7-24-2023-21-AS-DALO-CU2S4J-20230724133248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803113
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:32:52 PM

Document Has Been Signed on 07/24/2023 01:32 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 PARK		FACILITY NUMBER:	496803113
ADMINISTRATOR:	DAVIS, SHANNON		FACILITY TYPE:	775
ADDRESS:	125 SOUTHWEST BLVD		TELEPHONE:	(707) 664-8000
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY: 45		CENSUS: 32	DATE:	07/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Shannon Davis-Administrator		TIME COMPLETED:	01:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst(LPA), Alviso conducted a Required- 1 Year visit, on 7/24/23 at approximately 9:10am, and met with Administrator Shannon Davis. There were eight(8) clients on-site, and all other clients were in the community. LPA observed six(6) staff working on-site during the inspection. Day program has a fire clearance for forty-five(45)) capacity, of which twenty(20) may be non-ambulatory. Currently there are thirty-two(32) clients that attend day program. Some clients access the community, and others may choose to stay at the day program. The facility has a required infection control plan. The facility has a required emergency disaster plan. Facility does have emergency supplies, including supplies to meet a 72-hour shelter in place; There is a first aid kit with emergency supplies. Fire drills are held monthly, including evacuation of the building. Last fire drill was completed on 6/26/23. The LPA reviewed five(5) staff files. All staff have criminal record clearance as required. All staff have First Aid and CPR Certification. LPA reviewed staff training. The LPA reviewed five(5) client files. All the client files were found to be complete. The LPA toured the facility with the Administrator. Hot water was checked at 108.5F, which is within regulation. All exits were unobstructed. All eleven(11) fire extinguishers were serviced and tagged as required. Carbon monoxide detectors, four(4), were checked and working properly during the inspection. LPA observed the facility's supply of personal protective equipment (PPE) for use as needed. Continued on LIC809C...

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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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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: 07/24/2023

NARRATIVE

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Facility had a sufficient supply of cleaners, and paper products. Transportation vehicles have fire extinguishers and first aid kits. The facility had a First Aid bag, and a large mounted First Aid metal cabinet, with all required supplies. The facility has a kitchen area with appliances, and some snack items; The facility was observed to be clean and orderly during today's inspection. Facility was observed to be at a comfortable temperature.

LPA is requesting the following documents be submitted to CCL by 8/24/18:
LIC500 Personnel Report
LIC308 Designation of Responsibility
LIC610 Emergency Disaster Plan-updated as needed
Infection Control Plan-Updated as needed

While touring with the Administrator the LPA observed the facility's back patio area to have a large area with cracked asphalt that is a hazard for clients that use the outside activity area; LPA observed there are other smaller areas of asphalt on the patio that have cracks that may be a hazard to clients using the outside area, This deficiency will be cited, Outdoor Activity Space 82087.2(a)(1), If outdoor activity space is provided, it shall: Be free of hazards, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator. Appeal Rights provided.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/24/2023 01:32 PM - It Cannot Be Edited

Created By: Dina Alviso On 07/24/2023 at 01:05 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: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82087.2(a)(1)

Outdoor Activity Space

(a) If outdoor activity space is provided, it shall: (1) Be free of hazards. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observed the facility's back patio area to have a large area with cracked asphalt that is a hazard for clients that use the outside activity area; LPA observed there are other smaller areas of asphalt on the patio that have cracks that may be a hazard to clients using the outside area, the licensee did not comply with the section cited above in the facility's outdoor activity space, which poses/posed a potential health, safety or personal rights risk to persons in care. LPA obtained pictures.
	POC Due Date: 07/31/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure the outdoor activity space is inspected, repaired, and made safe for client's use while in care at the facility. Ensure that outdoor space is made safe while working on repairs needed to the outdoor activity space. Submit plan of correction as discussed, plan of safety, and completion date of any repairs. POC due 7/31/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Carla Martinez

LICENSING EVALUATOR NAME:

Dina Alviso

LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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