557005053-6-18-2025-27-AS-ELIM-DHRTU9-20250618150200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 557005053
Report Date: 06/18/2025
Date Signed: 06/18/2025 03:04:16 PM

Document Has Been Signed on 06/18/2025 03:04 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	COMMUNITY COMPASS, INC., THE		FACILITY NUMBER:	557005053
ADMINISTRATOR/ DIRECTOR:	SKIDMORE, RICHARD		FACILITY TYPE:	775
ADDRESS:	19411 SUSAN WAY		TELEPHONE:	(209) 588-1364
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY: 35		CENSUS: 3	DATE:	06/18/2025
TYPE OF VISIT:	Required - 1 Year	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:45 AM
MET WITH:	Bruno Diaz, Program Supervisor		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 10:45 AM on 6/18/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection and was greeted by a staff instructor (S1). The LPA identified herself, explained the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). The Program Supervisor (S2) was on-site and showed the LPA the LIC 310 designating him administrative responsibility in the DFA’s absence. The LPA conducted an interview with S2 and then toured the facility with him. This facility is a day program that is licensed to serve 35 clients. The census was two staff and three clients at the time of the site visit. When the LPA arrived, the clients were in the front activity room working on projects. Three other staff were in the community with nine clients. All five staff have criminal background clearances per Guardian. The facility consisted of one large activity area, three smaller activity areas, three offices, two bathrooms, and a kitchen. Upon entering the facility, the LPA toured the large, front activity room. The LPA observed required postings right inside the door, including the license, insurance, Provider Information Notices, and Disaster Plan. This room had laminate flooring and five large folding tables with chairs. S2 stated that clients did arts and crafts and ate lunch in this room. Three computer workstations are located on two of these tables. The room was divided by a sliding divider, which was open at the time of this visit. On the other side of the divider, the LPA observed two couches, carpeted flooring, and a large television. S2 stated that clients watch instructional, physical fitness, and recreational videos in this room. The thermostat is set at 71 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMUNITY COMPASS, INC., THE	FACILITY NUMBER: 557005053
	VISIT DATE: 06/18/2025

NARRATIVE

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The LPA toured a small hallway off the right side of the front, large activity area. A locked cabinet is located in this hallway that contained disposable briefs and wipes. The LPA observed a men’s and a women’s bathroom off this hallway. Both bathrooms contained two stalls, a sink, grab bars near the toilet, and a trash can with a closed lid. The bathrooms are clean and odor-free.

The LPA toured a short hallway that led off the backside of the large activity area. The LPA observed a closet with two louvered doors that were locked together with a small padlock. This closet contained a washer and dryer and two upper cabinets over the machines that contained cleaning supplies, which were inaccessible to clients.

The LPA toured the kitchen at the end of this short hallway. The kitchen contained a standing, upright freezer and a refrigerator/freezer unit, which was kept locked. These units contained very few things and are mostly used to cool water for off-site program activities and food for cooking classes. They were clean, operable, and odor-free. The LPA observed a trash can with a lid and a locked pantry that contained non-perishable food and sharps. There was a fire extinguisher on the wall near the back door of the kitchen. The LPA observed that it was last serviced on June 11, 2024 by Cisco Fire Sprinklers Inc. in Copperopolis. The LPA measured the hot water at the kitchen sink at 106 degrees Fahrenheit.

The LPA toured the small, locked office opposite the laundry. This is used by the Program Manager and contained a desk and office supplies. The LPA observed that several first aid kits are stored in a locked upper cabinet in this office, and all the required elements were present. The LPA also observed centrally stored medication in this locked upper cabinet. At the time of this vist, staff assisted two clients with medication administration. The LPA observed the paper-based medication administration record, which was current and complete.

The LPA toured a staff bathroom, one small office, and three smaller activity areas in the back of the facility. One activity area contained art supplies, another contained physical fitness equipment, and the third contained a table and an exercise mat. All of these areas were clean and contained activity equipment for clients in good repair.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMUNITY COMPASS, INC., THE	FACILITY NUMBER: 557005053
	VISIT DATE: 06/18/2025

NARRATIVE

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S2 tested three smoke detectors and all three sounded an alarm. All four of the fire extinguishers in the facility were last serviced on June 11, 2024 by Cisco. S2 called Cisco during the visit and set an appointment to have them serviced on Friday, June 20, 2025. The LPA observed copies of monthly smoke detector check logs and monthly disaster drill logs.

The LPA conducted a records review. She reviewed three client records and two staff records and found them to be complete.

The LPA requested that updated copies of these documents be submitted to her at ellen.lindstrom@dss.ca.gov by 5:00 PM on 07/03/2025:

(1) LIC 308 Designation of Facility Responsibility
(2) LIC 610 Emergency Disaster Plan
(3) Proof of Liability Insurance
(4) LIC 500 Personnel Report
(5) LIC 309 Administrative Organization

As a result of this inspection, the facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6. There were no deficiencies at this time.

An exit interview was conducted with the Program Supervisor, to whom a copy of this signed LIC809 report was provided. Their signature below confirms receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC809 (FAS) - (06/04)

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