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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804023
Report Date: 02/22/2022
Date Signed: 02/22/2022 03:01:58 PM

Document Has Been Signed on 02/22/2022 03:01 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:
02/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Glenn Vargas-ApplicantTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA), Alviso conducted a continued pre-licensing inspection and met with applicant Glenn Vargas Director, and Leonardo DelaCruz, Lead Staff.

The LPA observed some furniture has been brought in, table, chairs, computers for client use, activities/games, exercise bike, two couches, office furniture, and music items for the music room. LPA observed a PPE supply was added as requested from the last inspection. The applicant will also bring in a 30 day surgical mask supply for use by staff, and others as needed and/or required. The current PPE supply only had N95 masks available.

LPA observed the screening area which included a automatic temperature reading machine, log book with screening questions.
LPA observed that the PGE was turned on, and checked the hot water temperature, which was 136.F, above regulation water temperature allowed; Hot water must be no lower than 105.F and no higher than120.F per regulations. LPA rechecked the hot water and it was found to be 99.3F, under 105.F . Applicant will ensure that the hot water temperature is brought into compliance regarding hot water temperature, between 105.F and 120.F, per regulation 82088(e)(1) .

Applicant agreed to notify the LPA and submit a picture of the surgical mask supply brought into the day program site no later than 3/1/22.
Applicant agrees to submit self certification of the checked hot water temperature, ensuring it is now no lower than 105.F and no higher than 120.F, and facility plan in how the hot water will be maintained within regulations. This is due no later than 3/1/22.

Once all items are reviewed for completeness, the LPA will forward reports to the assigned Application Analyst in our Department; The Application Analyst will notify the Applicant of the status of the application.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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