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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830785
Report Date: 12/11/2025
Date Signed: 12/11/2025 11:35:28 AM

Document Has Been Signed on 12/11/2025 11:35 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/
DIRECTOR:		CLEIN GALANG, MARYFACILITY TYPE:
775
ADDRESS:1360 NORTH DUTTON AVETELEPHONE:
(650) 866-9367
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 30CENSUS: 28DATE:
12/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Mary Clein (Administrator)TIME VISIT/
INSPECTION COMPLETED:
11:55 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. Annual fees are current.

LPA/Administrator toured the facility at 9:00 am and made the following observations: Nurse's Office storages medications and they were locked, changing room with privacy screens, two restrooms, kitchen area, relaxation room, activities and conference rooms. Water in bathroom measured at 119.5 F which are within allowable range of 105 to 120 degrees F. Hygiene products were available for participant's use. Knives and other items that could pose a risk were locked. Passageways and ramps were free from obstructions. The facility does not handle cash resources. 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 four 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. 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 January 2025. The landlord is responsible for maintaining the sprinkler and smoke alarm system. Last disaster drill was conducted on November 25, 2025. Facility provides transportation for some participants.
Continue on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 12/11/2025
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Continued from LIC809...

LPA initiated a file review at 10:00 am. Seven participant files and five staff files were reviewed. Staff files reviewed had CPR/First Aid Certificates. However, according to administrator, staff training records binder was accidentally shredded by one of the participants and administrator is in the process of re-train staff to have records available for licensing agency to review. Participants files contains medical assessments and Individual services plans current.

A spot of medications revealed some discrepancies of two (Simethicone chew 80mg - take one tablet - three times daily and Acetaminophen 325mg - take two tablets by mouth three times daily) out of three medications for participant (P1) was not entered into the centrally stored medication log as stated per regulation.

-Administrator previously submitted updates of the following: Personnel Report (LIC 500) & lease agreement.

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.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2025 11:35 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 12/11/2025 at 11:16 AM
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: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(c)
Personnel Records
(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation, interview and record review, the licensee did not comply with the section cited above in all staff training records were accidentally shredded by participant, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
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Administrator agrees to re-train staff and document training hours to have them available for LPA to review. LPA will return to review training records of staff. Administrator will submit self-certification form (LIC9098) to CCL by not later than POC due date of 1/5/26.
Type B
Section Cited
CCR
82075(l)
Health-Related Services
(l) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation, interview & record review, the licensee did not comply with the section cited above in two out of three participant's (P1) medication was not entered into the centrally stored medication log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
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Administrator agrees to review all participant's medications and document them into the centrally stored medication log appropriately. Administrator will submit self-certification form (LIC9098) to CCL by not later than POC due date of 1/5/26 ensuring that all participant's medication records have been reviewed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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