<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803646
Report Date: 11/09/2023
Date Signed: 11/09/2023 12:08:22 PM

Document Has Been Signed on 11/09/2023 12:08 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: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: 22DATE:
11/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Povi Wagner (Administrator)TIME COMPLETED:
12:23 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 Cuadra (LPA) arrived unannounced to conduct an Annual Required inspection and met with Administrator, Povi Wagner. This Adult Day Program is currently providing services on Monday through Friday 8am to 3pm. Participants were engaged in personalized activities.

LPA/Administrator initiated a tour of the facility and observed the following: Facility has a large open area, a nurse room, two rooms for different activities in addition to two changing rooms, administrative office, two bathrooms, kitchen and a dining area. Facility was a comfortable temperature and passageways were free from obstructions. LPA observed a calendar with different activities for clients in care for current week. Clients bring their own food to day program and store it in the refrigerator or a designated cubby. The refrigerator designated for client lunches and snacks was clean and dry. Program does not provides transportation. Water temperature was measured between 112.3 and 112.8 degrees F in bathrooms used by clients which are within regulation of 105 to 120 degrees F. Toxins are located in a locked room in the garage. Medications are centrally stored in a locked medication cart. Required posters observed. Two out of two fire extinguishers were serviced and charged December 2022. Sprinklers and fire alarm system are maintained by the City of Santa Rosa Fire Department and was last served on October 2023. Carbon monoxide detector was tested and functional at time of visit. Most recent fire/disaster drill was conducted 10/18/2023.

LPA initiated file review at 9:00am. Five staff and ten client files were reviewed. Staff records have training hours records and First Aid/CPR training. All client files had medical assessments, needs and services plan updated. Facility has two licensed staff (LVN and RN) and are in the facility when clients are present.
Administrator provided copies of the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500). 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: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1