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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804023
Report Date: 01/24/2024
Date Signed: 01/24/2024 02:22:22 PM

Document Has Been Signed on 01/24/2024 02:22 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: 37DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Glenn Vargas-AdministratorTIME COMPLETED:
02:20 PM
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Licensing Program Analysts (LPA) Alviso conducted a Required - 1 Year inspection, on 1/24/24 at approximately 9:35am, and met with Administrator Glenn Vargas. Today there were nineteen (19) staff working at the program, including the Administrator.

Currently the facility is operating with 37 clients on-site;The Program operates on-site Monday through Friday, 9am to 3pm. Facility has a fire clearance approval by the Rohnert Park Fire Department for a total of 50 ambulatory, and 10 non-ambulatory. The facility has a required infection control plan. The facility has a required emergency disaster plan. The facility's last emergency drill was completed on 12/29/23, per review of records. LPA reviewed ten (10) staff files. All staff had first aid and cpr certification. All staff had training as required.LPA reviewed ten (10) resident files. All resident files were complete.
The facility has a lot of activities for the clients, a computer room, exercise room, a movie room, art room, and music room. The program has a large open area with tables, tv, couch, kitchen area, and activities going on. The program has a laundry room that is kept locked and inaccessible to clients in care. Cleaners and disinfectants are locked up and inaccessible to clients in care. All bathrooms, four (4), were observed to be clean and orderly. All walkways and exits were unobstructed and clear. Fire extinguishers, three (3), were serviced and tagged. Carbon monoxide detector was working properly during the inspection. The facility has a refrigerator to hold drinks/water, and client lunches and snacks. The stove knobs have covers that make them inaccessible to clients in care.
Licensee to submit the following annual forms by 2/24/2024:
LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610D- Emergency Disaster Plan-updated & reviewed as needed. submit copy if changes, submit last page signed and dated if no changes.
LIC400-Affidavit Regarding Client Cash Resources
LIC402-Surety Bond (if handling client cash)
Infection Control Plan-updated & reviewed as needed-submit copy if changes, submit last page signed and dated if no changes.

No deficiencies cited today.
Exit interview conducted with Administrator Glenn Vargas.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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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