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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830785
Report Date: 01/30/2025
Date Signed: 01/30/2025 02:09:35 PM

Document Has Been Signed on 01/30/2025 02:09 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:M3 DAY PROGRAMFACILITY NUMBER:
496830785
ADMINISTRATOR/
DIRECTOR:		CLEIN GALANG, MARYFACILITY TYPE:
775
ADDRESS:1360 NORTH DUTTON AVETELEPHONE:
(650) 866-9367
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 30CENSUS: 25DATE:
01/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:12 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Deniz and 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.

LPAs/Administrator initiated a tour of the facility at 11:30 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 70 F which are not within allowable range of 105 to 120 degrees F. Toilet facilities are well maintained with paper products and with handicap equipment. Men's restroom which located in the main area, the garbage bin doesn't have lid or cover on. But Administrator replaced the garbage bin with a new one.(TV was issued). 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.

Continued from LIC 809...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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Document Has Been Signed on 01/30/2025 02:09 PM - It Cannot Be Edited


Created By: Ali Deniz On 01/30/2025 at 01:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: M3 DAY PROGRAM
FACILITY NUMBER: 496830785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs/Administrator observation, the licensee did not comply with the section cited above in one out of two bathrooms used by participants 70 F degrees which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Administrator agrees to contact building management to adjust the water temp. and will monitor the water temp. for next seven days. Administrator will submit the water temp. log to the CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Ali Deniz
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: M3 DAY PROGRAM
FACILITY NUMBER: 496830785
VISIT DATE: 01/30/2025
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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 March 30, 2024. The landlord is responsible for maintaining the sprinkler and smoke alarm system. Last Disaster Drill was conducted on January 27, 2025. 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 12:15 pm. Five participant files and five staff files were reviewed. Staff files reviewed had First Aid Certificates. Participants files contains medical assessments and Individual services plans are current.

Administrator will provide updates of the following documents: Designation of Administrative Responsibility (LIC 308), Personnel Report (LIC 500), Emergency Disaster Plan (610E) and lease agreement by no later than February 7, 2025 .

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview was conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC809 (FAS) - (06/04)
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