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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830785
Report Date: 11/19/2021
Date Signed: 11/19/2021 01:18:31 PM

Document Has Been Signed on 11/19/2021 01:18 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:M3 DAY PROGRAMFACILITY NUMBER:
496830785
ADMINISTRATOR:CLEIN GALANG, MARYFACILITY TYPE:
775
ADDRESS:1360 NORTH DUTTON AVETELEPHONE:
(650) 866-9367
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 30CENSUS: 0DATE:
11/19/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:56 AM
MET WITH:Mary Clein (Administrator)TIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Cuadra arrived to conduct a Case Management inspection is intended to observe precautions taken by the day program services and review re-entry plan for in-person classes and met with Administrator, Mary Clein. Facility is not currently open and is not providing on site day program services but is starting to initiate a reopening plan. The program re-entry plan consists in three phases including the duration time, number of participants that will be accepted in the facility and a description of the precautions that will be followed to ensure the mitigation of the spread of the virus.

During Phase #1 of the re-entry plan, 6 participants will be receiving in-person services between the months of December 2021 and January 2022, but it will be subject to change depending on Covid19 related guidance. Participants will be scheduled five days a week from 9:00am to 3:00pm. Other participants will still be provided with alternative services through zoom classes, self guided materials and van rides. Participants will be grouped together as much as possible depending on if they live in the same household or staff will ensure to maintain social distancing and proper hand washing during activities and lunch. Participants will wear face coverings as tolerated. However, staff must wear mask when care and supervision is being provided to participants. Transportation services will be provided by R&D that will ensure to follow current guideline and If a participant is exhibiting symptoms, they are to stay home and notify the facility. Phase #2: Capacity will be increased to 12 participants between the months of February & March 2022, but it will be subject to change depending on current Covid19 state guidance. Phase #3: Facility will be back to full capacity depending on current Covid19 guidelines between the months of April 2022 and forward. Staff will screen all participants, visitors and staff upon arrival and sign them in. Day Program consists of a large area that will ensure social distancing between staff and participants. Facility has posters that are posted through the site. Per Administrator, there are sufficient personal protective equipment for staff and participants. Facility has submitted their Mitigation Plan and was approved as of 2/8/2021. Currently, there is 100% rate of vaccinated staff. All staff have received required training on infection control and staff have been N95 fit tested. Facility has a cleaning plan to sanitize tables, chairs, activity materials and restrooms after each use.
No deficiencies were cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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