<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830785
Report Date: 05/10/2022
Date Signed: 05/10/2022 10:17:43 AM

Document Has Been Signed on 05/10/2022 10:17 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: 4DATE:
05/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Mary Clein (Administrator)TIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 currently open providing on-site day program services Monday through Friday between 9am to 3pm. The facility provided a three phases program re-entry plan 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.

LPA/Administrator toured the facility inside and outside, Day Program consists of a large area that ensures social distancing between staff and participants. Facility has posters that are posted through the site. There are sufficient personal protective equipment, incontinence care supplies and antigen test kits for participants. Facility has submitted their Mitigation Plan and was approved as of 2/8/2021. Currently, there is 100% rate of vaccinated staff including boosters. All staff have received required training on infection control and staff have been N95 fit tested. Facility has a cleaning log that staff will initial after sanitizing tables, chairs, activity materials and restrooms will be cleaned after each use. Facility performs daily screening of all participants, visitors and staff upon arrival and sign them in a clipboard. During Phase #1 of the re-entry plan, 10 participants will be receiving in-person services between the months of May 2022 and July 2022. However, during today's visit there was only four clients. Per Administrator, there were only four clients who choose to receive in-person services. Participants are scheduled in a traditional manner. Other participants are offered alternative services through zoom classes, self guided materials and van rides. Participants were observed grouped together as much as possible, staff was ensuring that they maintain social distancing during activities. Participants were observed wearing a face covering as tolerated. Also, staff was observed wearing masks. Transportation services are provided by R&D that ensures 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 20 participants between the months of August and September 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 October 2022 and forward.
No deficiencies were cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1