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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830785
Report Date: 02/09/2023
Date Signed: 02/09/2023 10:08:22 AM

Document Has Been Signed on 02/09/2023 10:08 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: 20DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Mary Galang (Administrator)TIME COMPLETED:
10:23 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Administrator, Mary Clein. This inspection is based on infection control practices at this facility. Currently the facility is operating with 25 participants on-site Mon-Friday between 8:00am to 4:00pm.

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 participants daily screening. Participants were observed participating in personalized activities. Facility provides transportation services by R&D that ensures to follow current guidelines. Participants bring their own snacks and lunches. Staff was observed wearing a mask while in the facility. Participants wear face coverings as tolerated. All staff continues receiving required training on infection control and they have been N95 fit tested. Regular maintenance plan includes sanitizing and cleaning after conclusion of each activity. Facility has automated dispensers to dispense hand sanitizer. Facility has submitted their Mitigation Plan and was approved as of 2/8/2021. Facility has posters that are posted through the facility encouraging participants to wear a mask, wash their hands, cough etiquette and maintain social distancing. Facility has sufficient personal protective equipment for staff and participants including face shields, gloves, hand sanitizer and masks. Last disaster drill was conducted on December 21, 2022, Fire extinguishers were found serviced and charged as of April 2022. Maintenance is provided by landlord of the building including smoke detectors and fire sprinklers.

Facility provided updated copies of the following documents: Designation of Responsibility (LIC308), Administrative Organization (LIC309), Affidavit Regarding Client Cash Resources (LIC400), Surety Bond, Control of Property and Personnel Report (LIC500).
Exit interview was conducted with Administrator and a copy of this report was given.
No deficiencies were cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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