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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803646
Report Date: 09/08/2022
Date Signed: 09/08/2022 10:33:13 AM

Document Has Been Signed on 09/08/2022 10:33 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 13DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Povi Wagner (Licensee)TIME COMPLETED:
10:44 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an annual Required-1 year inspection focused on the Infection Control procedures and practices of this Adult Day Program. LPA met with staff Andrea Faivre. Licensee/Administrator, Povi Wagner arrived later. This Adult Day Program is currently providing in-person services on Monday-Friday 8am to 3pm.
During today's visit there are 13 participants that 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 and boosted. 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. 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 also 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. LPA observed Covid19 related posters through the facility including restrooms. Facility has sufficient personal protective equipment for staff and participants including 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. Facility submitted their Infection Control Plan for CCL to review. Fire Extinguishers were found to be last charged on December, 2021 and their last disaster drill was conducted on June 22, 2022.

Administrator provided updated copies of the following: LIC309 Administrative Organization, LIC 308 Designated Administrator, LIC 610 Emergency Disaster Plan, LIC 400 Affidavit Regarding participants Cash Resources & Copy of current Lease/Rental Agreement.

Exit interview conducted with Povi Wagner and a copy of this report was provided to the Administrator.

No deficiencies cited during today's inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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