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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804023
Report Date: 02/07/2022
Date Signed: 02/07/2022 04:04:43 PM

Document Has Been Signed on 02/07/2022 04:04 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:INCLUSION CONCEPTSFACILITY NUMBER:
496804023
ADMINISTRATOR:VARGAS, GLENNFACILITY TYPE:
775
ADDRESS:4 PADRE PARKWAY, SUITE BTELEPHONE:
(650) 270-3030
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 60CENSUS: 0DATE:
02/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Glenn Vargas-Applicant/LicenseeTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA), Alviso conducted a pre-licensing inspection and met with applicant Glenn Vargas Director, and Leonardo DelaCruz, Lead Staff.

Facility has a fire clearance approval by the Rohnert Park Fire Department for a total of 50 ambulatory, and 10 non-ambulatory-effective 10/20/2021.

Facility will operate the day program five days a week, Monday - Friday, 9am to 3pm.

There are four bathrooms for staff, and resident use. All postings were up as required.
All exits were unobstructed in the home. All utilities were on and operational except for the gas; PG&E will be turning the gas on 2/8/22. Furniture and other items, including computers will be ordered in the next few weeks and set up in the day program space. The screening area at the front entrance will be set up as needed, and the PPE supply will be counted and items brought in to ensure a 30 day PPE supply. The applicant stated that he is still working on setting things up for the day program, and waiting for the vendorization to come through as needed for the day program operation.

LPA completed Component III with applicant Glenn Vargas. Mr. Vargas has operated an adult day program for approximately the last 71/2 years, and currently has an adult residential facility.

Once the items discussed and mentioned by the LPA in the report are complete, the applicant Glenn Vargas will contact the LPA to schedule a return to continue the pre-licensing inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2022
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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