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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803646
Report Date: 03/30/2023
Date Signed: 03/30/2023 01:17:44 PM

Document Has Been Signed on 03/30/2023 01:17 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: 16DATE:
03/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Povi Wagner (Licensee)TIME COMPLETED:
01:32 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 (LPA) Cuadra arrived unannounced to conduct a Case Management inspection and met with Licensee, Povi Wagner.

CCL obtained information from an outside agency about an incident were participant (P1) was observed sitting by themselves with their shoes off, their shirt wet with their drool, and not engaged in any activities. When day program staff were asked, they had no documentation of activities the P1 was engaged in. They also did not have a schedule of activities for P1 or the other participants on file.

During today's visit, Licensee confirmed that this incident occurred and provided information that the day program prior to the pandemic used to develop a monthly schedule of personalized activities depending on their individual needs. However, they have been working on re-instating them, developing individualized schedule of activities for all on-site participants taking in considerations any changes of condition. Day program also provided LPA with P1's schedule of activities dated 3/23/23. Per Licensee, P1 resumed attending the day program on 11/08/22, but due to medical reasons they have not been attending to day program as scheduled two times per week. Therefore, it had been difficult to fully re-instate their individualized plan. Licensee informed LPA that the individualized scheduled of activities for all on-site participants will be complete by April 3, 2023 and agreed to submit a self-certification form (LIC90988) to notify LPA that such process is complete to get back in compliance with regulation.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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 2
Document Has Been Signed on 03/30/2023 01:17 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/30/2023 at 12:37 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: KALEIDOSCOPE ADULT DAY PROGRAM
FACILITY NUMBER: 496803646

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2023
Section Cited
CCR
82079(e)(2)

1
2
3
4
5
6
7
82079 Planned Activities (a) The licensee shall provide opportunities for, and encourage participation in activities. This requirement has not been met as evidence by:
1
2
3
4
5
6
7
Licensee/administrator agreed to re-instate monthly individualized schedule of activities for each participant to be engage in activities and will submit a self-certification LIC9098 confirming that the plans are in place for each participant.
8
9
10
11
12
13
14
During today's visit Licensee confirmed to LPA that P1's monthly individualized schedule of activities were suspended during the pandemic and are being re-instated for each participant. LPA observed there were no individualized schedule of activities plans for all participants. This is a potential risk to Health and Safety risk to residents in care
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2