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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203048
Report Date: 09/20/2021
Date Signed: 09/20/2021 12:47:25 PM

Document Has Been Signed on 09/20/2021 12:47 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:UNITED CEREBRAL PALSY OF STANISLAUS COUNTYFACILITY NUMBER:
507203048
ADMINISTRATOR:MARISOL MORENOFACILITY TYPE:
775
ADDRESS:4265 SPYRES WAY, SUITE #2TELEPHONE:
(209) 577-2122
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 75CENSUS: 61DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Marisol Moreno (Administrator)TIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPA) Sarah Hurt conducted an unannounced visit today for the facilities annual inspection. LPA met with Administrator Marisol Moreno. There are currently 12 residents who receive in person services at this location. LPA inspected the interior and the exterior of the facility activity rooms, kitchen, bathrooms and outdoor areas.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 108 F degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. There are currently no residents at this facility currently taking medications

There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, Emergency Disaster Plan and copy of current Administrator's current CE units to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator and copy of report left at facility
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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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