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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203048
Report Date: 08/09/2023
Date Signed: 08/09/2023 02:19:10 PM

Document Has Been Signed on 08/09/2023 02:19 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
SACRAMENTO AC/SC, 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: 47DATE:
08/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Marisol Moreno, Designated Facility AdministratorTIME COMPLETED:
02:30 PM
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On 08/09/23 Licensing Program Analyst, (LPA) Kimberly Viarella conducted an unannounced annual inspection of this facility. LPA met with the Designated Facility Administrator, Marisol Moreno and explained the purpose of the visit. There are currently 62 clients registered to receive services at this day program. Current census was 47. 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.

LPA observed that at this time, all toxins, knives, and scissors were kept in locked cabinets inside locked closets and inaccessible to clients.

Hot water was measured and found to be 114.8 degrees Fahrenheit and within the required range for compliance. LPA observed that the 2 fire extinguishers in the facility were both inspected on 03/08/23 by Jorgensen Co and were in compliance. This facility had a carbon monoxide detector and performed disaster drills as required.

All medications were locked and inaccessible to residents. LPA reviewed dosing, storage and destruction procedures with the Designated Facility Administrator. LPA inspected First Aid kit and found it to be complete and in compliance.

LPA completed a file review for staff and clients; 5 out of 5 staff/client files were complete and in compliance.
There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: UNITED CEREBRAL PALSY OF STANISLAUS COUNTY
FACILITY NUMBER: 507203048
VISIT DATE: 08/09/2023
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LPA previously requested that the following be submitted to kimberly.viarella@dss.ca.gov.:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 610-E file.
A copy of liability insurance

All were received and filed.

Exit interview conducted with Designated Facility Administrator Marisol Moreno and a copy of this report was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC809 (FAS) - (06/04)
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