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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803613
Report Date: 10/17/2023
Date Signed: 10/17/2023 01:18:56 PM

Document Has Been Signed on 10/17/2023 01:18 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:ALLIED INTEGRATION SERVICESFACILITY NUMBER:
496803613
ADMINISTRATOR:VANDERVILLE, ERICFACILITY TYPE:
775
ADDRESS:50 EXECUTIVE AVETELEPHONE:
(707) 586-1799
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 30CENSUS: 17DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dawn Cuellar-Program DirectorTIME COMPLETED:
01:12 PM
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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a Required -1 Year inspection and met with Program Director Dawn Cuellar.

Facility is fire cleared for thirty (30) clients, of which four (4) may be non-ambulatory. Facility has an infection control plan as required. Facility has an emergency disaster plan as required. Last fire drill was completed 10/9/23, which included all staff and clients on-site.

Currently there are seventeen (17) clients in care. All clients go into the community from the day program, and are supervised by day program staff. LPA reviewed six (6) client files. LPA reviewed six (6) staff files. All staff have criminal record clearance as required.

LPA toured the facility with the Director. Hot water was checked at 111. Fahrenheit. Fire extinguishers are tagged and serviced as required-10/6/23. All exits were clear and unobstructed. Facility was clean and orderly. Bathrooms were clean and had paper towels available for use as needed. Facility has arts and crafts supplies for activities.

Per LPA’s file review, staff #5 lacks required TB test & results. This deficiency will be cited, personnel requirements 82065(g)(1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure, see LIC809D.

The following deficiency(s) was 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.



Appeal Rights provided to the Program Director
Exit interview conducted with the Program Director
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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Document Has Been Signed on 10/17/2023 01:18 PM - It Cannot Be Edited


Created By: Dina Alviso On 10/17/2023 at 01:01 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: ALLIED INTEGRATION SERVICES
FACILITY NUMBER: 496803613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065(g)(1)
Personnel Requirements
(1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA’s file review, staff #5 lacks required TB test & results, the licensee did not comply with the section cited above in [1] out of( 6] files reviews, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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Licensee to ensure that staff #5 obtains a TB test & results as required. Submit a copy as proof of correction by POC due date of 10/27/23.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
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