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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804023
Report Date: 01/20/2023
Date Signed: 01/20/2023 04:39:51 PM

Document Has Been Signed on 01/20/2023 04:39 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: 28DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Glenn Vargas-AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analysts (LPA), Dina Alviso conducted a Required 1- Year inspection, on 1/20/23 at approximately 3:15pm, and met with Administrator Glenn Vargas. The inspection is focused on the Infection Control procedures and practices of this facility.
Currently the facility is operating with 28 clients on-site, Monday through Friday participating in face to face program services.

The LPA was screened at the front door entry; Staff are screening staff, clients, and visitors, per Administrator. All staff are screened at the main entrance before being allowed to work their shift. All clients are screened before getting onto the Program's transportation vehicle(s), and at the Day Program front entrance as they enter the building. The facility has an Infection Control Plan as required. There is a screening station up at the front counter as you enter the building. The LPA observed the facility's supply of personal protective equipment(PPE), and it was sufficient. The Administrator stated that they ensure a sufficient supply, minimum of one month at all times.

Facility has an approved fire clearance for sixty (60) residents, of which ten(10) may be non-ambulatory. All exits were observed to be cleared of any obstructions. Fire extinguishers were checked, they were found to be serviced, and tagged as required, expires 2/4/2023. The facility was at a comfortable temperature for clients attending day program. The facility had a supply of snacks for use as needed. There was a sufficient supply of cleaners/disinfectants, and paper products. The facility has activity equipment, games, movies, arts and crafts, exercise equipment, computers, and other items for client use. All appliances were working as required, Television with netflix and other applications for viewing movies and other items. The facility had electricity, lights on, heat was on, and facility phone service was working appropriately. The facility was observed to be clean and orderly.

No deficiencies cited.
Exit interview held with Glenn Vargas, Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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