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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203048
Report Date: 08/15/2022
Date Signed: 08/15/2022 12:54:26 PM

Document Has Been Signed on 08/15/2022 12:54 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: 64DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Marisol MorenoTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Program Manager Marisol Moreno and explained the purpose for today's visit. There are currently 64 clients who receive services at this day program. LPA inspected the interior and the exterior of the facility including staff and client bathrooms, and activity rooms, medication storage, kitchen, and outdoor areas. The areas observed were clean and in good repair. There is a locked storage for medications.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. This facility has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 114 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA verified all staff present is background cleared. LPA confirmed all staff has either COVID 19 vaccine care or exemption.

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

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator Marisol Moreno and copy of report left at facility
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2022
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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