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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804023
Report Date: 03/19/2025
Date Signed: 03/19/2025 05:11:39 PM

Document Has Been Signed on 03/19/2025 05:11 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:INCLUSION CONCEPTSFACILITY NUMBER:
496804023
ADMINISTRATOR/
DIRECTOR:		VARGAS, GLENNFACILITY TYPE:
775
ADDRESS:4 PADRE PARKWAY, SUITE BTELEPHONE:
(650) 270-3030
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 60CENSUS: 41DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Leonardo Delacruz-Administration Assistant StaffTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required - 1 Year inspection, on 3/19/25 at approximately 1:40pm, and met with Lead Staff, Nancy Vargas. Nancy Vargas contacted the Administration staff to notify them of LPA's arrival. Leonardo Delacruz, lead staff, arrived to the facility to meet with the LPA, and assist lead staff Nancy Vargas.

Facility has a fire clearance approval for a total of sixty (60) clients, of which ten (10) may be non-ambulatory. The facility has a required infection control plan. The facility has a required emergency disaster plan.

The count of today's client participants was noted at forty-one (41) Today there are twenty-four (24) staff working at the program. The Program operates on-site Monday through Friday, between 9am to 3pm. LPA observed majority of the clients but a couple at the front entrance preparing to leave day program on the arriving transportation vehicles.

LPA reviewed six (6) client files. LPA reviewed six (6) staff files. All staff have criminal record clearance as required. All staff have annual training. All staff have first aid certification and CPR certification.

LPA toured the facility with lead staff Leonardo and lead staff Nancy Vargas. All exits were clear and unobstructed. Fire extinguishers, three (3) were observed to be fully charged. Facility has sufficient lighting throughout the program site. There are variety of games and art supplies for client use. There is a movie room, sensory room, computer room, exercise gym room, music room, a large open common area with a television, tables and chairs; There is a kitchen area with a refrigerator, on the back wall of the common area, for use by clients attending day program. There is also a meeting room, storage room, laundry room, and a small salon room. Bathrooms used by the day program participants had hygiene supplies for use as needed.
Continued on LIC809C....
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: INCLUSION CONCEPTS
FACILITY NUMBER: 496804023
VISIT DATE: 03/19/2025
NARRATIVE
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Disinfectants/cleaners were locked and inaccessible to clients in care. Sufficient supply of paper products, cleaners/disinfectants, soap, sanitizer, and personal protective equipment (PPE) for use as needed. There was sufficient furnishings for client use.

Licensee to submit the following annual forms by 4/19/25:
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.

The following deficiencies were observed during the inspection:

LPA checked hot water in a bathroom sink, used by day care participants, and it measured at 139.4 degrees Fahrenheit which is not within regulation of no higher than 120. degrees Fahrenheit. This deficiency will be cited, 82088(e)(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C), see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Supervisory lead staff Nancy Vargas and Leonardo Delacruz. Appeal Rights provided to the staff.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/19/2025 05:11 PM - It Cannot Be Edited


Created By: Dina Alviso On 03/19/2025 at 04:52 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: INCLUSION CONCEPTS
FACILITY NUMBER: 496804023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA checked hot water in a bathroom sink, used by day care participants, it measured at 139.4 degrees Fahrenheit which is not within regulation of no higher than 120. degrees Fahrenheit, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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CLEARED-LICENSEE TURNED DOWN THE HOT WATER HEATER AND AT THE END OF COMPLETING THE REPORT, HOT WATER WAS MEASURED AT 105.08 DEGREES FAHRENHEIT. LICENSEE TO CHECK AND LOG HOT WATER FOR A PERIOD OF FIVE DAYS ENSURING HOT WATER IS NO HIGHER THAN 120 DEGREES AND NO LOWER THAN 105.DEGREES FAHRENHEIT. FOLLOW-UP, SUBMIT HOT WATER LOG BY 3/25/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


LIC809 (FAS) - (06/04)
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