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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803646
Report Date: 11/19/2024
Date Signed: 11/19/2024 10:52:59 AM

Document Has Been Signed on 11/19/2024 10:52 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/
DIRECTOR:
WAGNER, POVIFACILITY TYPE:
775
ADDRESS:325 TESCONI CIRCLETELEPHONE:
(707) 230-2895
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 40CENSUS: 32DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:57 AM
MET WITH:Giovana Capra (Manager)TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst Cuadra (LPA) arrived unannounced to conduct an Annual Required inspection and met with Manager, Giovana Capra. The day program is open Monday through Friday 8am to 3pm.

LPA/Manager initiated a tour of the facility and observed the following: 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. Participants were engaged in personalized activities. Clients bring their lunches. The refrigerator designated for client lunches and snacks was clean and dry. Program does not provides transportation. Water temperature was measured between 111.7 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. Fire extinguishers were serviced and charged December 2023. Sprinklers and fire alarm system are maintained by the City of Santa Rosa Fire Department and was last served on October 2024. Carbon monoxide detector was tested and functional at time of visit. Most recent fire/disaster drill was conducted 10/16/2024. Annual fees are current. First aid kit was present.

LPA initiated file review at 9:00am. Four 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 will provide copies of the following documents by not later than 11/27/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500).

No deficiencies cited during today's inspection. Exit interview conducted with Manager and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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