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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830785
Report Date: 02/03/2022
Date Signed: 02/03/2022 11:33:36 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/03/2022 11:33 AM - 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: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:
02/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mary Clein (Administrator)TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Cuadra arrived to conduct an Annual Required inspection and met with Administrator, Mary Clein. Starting in December 2021, the facility had a re-entry plan for in-person classes. However, due to Covid19 guidelines they did not proceed with the reopening plan.

The program is not open for in-person classes, there are 16 participants that are receiving alternative services through online activities and staff drop off activity packages including arts and crafts supplies for participants in average once a week. LPA arrived at the facility and had their temperature checked and logged. Facility has a centralized sign-in sheet located at loading area where facility documents staff, visitors and eventually participants daily screening. All staff are completely vaccinated. Facility will provide transportation services 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. The facility also will screen participants at facility entrance. Staff was observed wearing a mask while in the facility. All staff have received required training on infection control yet and were fit tested for N95. Regular maintenance plan includes sanitize every two hours or as needed. Facility has automated dispensers to dispense hand sanitizer. 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 and boosted. Facility has posters that are posted through the facility encouraging participants to wear a mask and maintain social distancing. Facility has sufficient personal protective equipment for staff and participants including face shields, gloves, hand sanitizer and masks. Facility has submitted their Mitigation Plan and it was approved as of 4/13/21. Administrator agreed to notify CCL before re-opening for in-person classes.

During today's visit, Administrator provided the following documents: Designation of Responsibility (LIC308), Emergency Disaster Plan (LIC610E), Lease agreement and Personnel Report (LIC500).

No deficiencies were cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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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