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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803646
Report Date: 09/16/2021
Date Signed: 09/16/2021 11:10:34 AM

Document Has Been Signed on 09/16/2021 11:10 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:KALEIDOSCOPE ADULT DAY PROGRAMFACILITY NUMBER:
496803646
ADMINISTRATOR:WAGNER, POVIFACILITY TYPE:
775
ADDRESS:325 TESCONI CIRCLETELEPHONE:
(707) 230-2895
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 40CENSUS: 8DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Claudia Rosas (Staff)TIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an annual required inspection based on infection control and met with staff, Sidona Sylva and Claudia Rosas; Administrator, Povi Wagner was not able to come to the facility, but was available by phone and gave authorization for staff to sign the report. LPA conducted risk assessment call with staff Sidona Sylva prior to make a visit. The program is open Monday through Friday from 8:00am to 3:00pm.

LPA arrived at the facility and had temperature checked and logged. There are 8 participants at the time of visit. Participants were observed participating in personalized activities. Facility has a centralized sign-in sheet where documents staff and participants daily screening. All staff and clients are completely vaccinated. Participants wear face coverings as tolerated. Staff was observed wearing a mask while in the facility. Day program does not provide transportation. Transportation services are provided by R&D and different vendors which will ensure to follow all the precautions. Facility has three licensed staff (LVN, RN and RN consultant) and are in the facility when clients are present. Per licensee, all staff have received required training on infection control. Facility is conducting surveillance testing for 25% of staff every 7 days.

There are 2 restrooms and three toilets available for participant use. Facility has a cleaning log and also cleans every hour or after every use. Facility has two changing rooms. Participants have their own mat and cleaning supplies. Additional tables and chairs were removed to ensure social distancing between staff and participants. Facility has posters that are posted through the facility except bathrooms. LPA provided via email Covid19 related posters to post in bathrooms. Facility has sufficient personal protective equipment for staff and participants including face shields, gloves, hand sanitizer and masks, participants bring their own meals. If a participant is exhibiting symptoms, they are to stay home and notify the facility. Facility has submitted their Mitigation Plan and it was approved as of 3/16/21.

No deficiencies were cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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