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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830785
Report Date: 02/06/2024
Date Signed: 02/06/2024 10:41:13 AM

Document Has Been Signed on 02/06/2024 10:41 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: 30DATE:
02/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Mary Clein (Administrator)TIME COMPLETED:
10:56 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Administrator, Mary Clein Galang. Day Program is open Monday thru Friday 8am-4pm.

LPA/Administrator initiated a tour of the facility at 9:00 am and made the following observations: Day Program is located in a large building that consists of a central multi-purpose area that is also used as a dining area. Along the perimeter of the space there is an Administration Office, Nurse's Office where medications were centrally stored and locked, changing room with privacy screens, two restrooms, kitchen with functioning appliances, relaxation room, Computer/Activity Room and a Library/Conference Room. Water in bathrooms measured at 114 F and 115 F which are within allowable range of 105 to 120 degrees F. Toilet facilities are well maintained with paper products and with handicap equipment. No hazards were observed in the indoor and outdoor activity areas. Medications and medication records were reviewed. The facility does not handle cash resources. In the hallway near the personal care room there are designated cubbies for participants to store their items. Knives and other items that could pose a risk were locked.

Participants bring their own snacks and lunches. Refrigerators for participant lunches were clean. A cabinet in the kitchen contains emergency supplies. The facility is assisting to feed 4 participants through G-tubes. LPA was able to verify that facility maintains a day supply of client prescribed nutritional formulas and supplies which are provided daily from participant's home. LVN is responsible for all tube feeds and medication management.
Continues on LIC 809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: M3 DAY PROGRAM
FACILITY NUMBER: 496830785
VISIT DATE: 02/06/2024
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Continued from LIC 809...

RN consultant comes every month to conduct in-service training for staff and is available over the phone for any consult. The facility's fire extinguishers were last serviced April 7, 2023. The landlord is responsible for maintaining the sprinkler and smoke alarm system. Last Disaster Drill was conducted on January 31, 2024. Facility provides transportation for some participants. Facility van was inspected and contained a first aid kit and fire extinguisher was charged and serviced. The staff and participant ratio at this day program is 2:1. Activity calendar was observed current and posted.

LPA initiated a file review at 10:00 am. Ten participant files and three staff files were reviewed. Staff files reviewed had First Aid Certificates. Participants files contains medical assessments and Individual services plans are current.

Administrator provided updates of the following documents: Designation of Administrative Responsibility (LIC 308), Personnel Report (LIC 500), Emergency Disaster Plan (610E) and lease agreement.

No deficiencies cited during today's visit. Exit interview was conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024
LIC809 (FAS) - (06/04)
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