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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577001513
Report Date: 11/02/2023
Date Signed: 11/02/2023 01:39:53 PM

Document Has Been Signed on 11/02/2023 01:39 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ADULT TRAINING PROGRAMFACILITY NUMBER:
577001513
ADMINISTRATOR:JENNIFER VELAFACILITY TYPE:
775
ADDRESS:220 HARTER AVENUETELEPHONE:
(530) 406-0830
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 45CENSUS: 28DATE:
11/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Jennifer Veala, AdministratorTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Required Inspection. LPA met with Administrator Jennifer Vela. The program serves up to 45 developmentally disabled clients. Client to staff ratios are typically 1:8 on site unless a client's care plan specifies otherwise. There were 26 clients participating on site today, with 4 staff providing direct supervision.

A tour of the facility was conducted which was found to be clean, in good repair and comfortable temperature. The facility consists of a kitchen, 2 bathrooms, 1 great room used for class, arts and crafts and exercise, an outdoor patio, a conference room and a staff office.

Bathrooms contained necessary grab bars, hygiene products and continence care products available for client use. Hot water measured 116.5 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by clients. Participants typically bring their own lunches and snacks unless there is a party or special occasion. All exits were found to be unobstructed. All items that could constitute danger were found to be inaccessible at the time of the visit. 4 Fire extinguishers were observed to be present with an inspection tag date of 10/19/2023. Smoke detectors were tested and found to be working at the time of the visit. A fire inspection was conducted on 10/03/2023. A Disaster Drill was conducted during the Great Shake-Out on 10/19/2023.

Continued.....
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ADULT TRAINING PROGRAM
FACILITY NUMBER: 577001513
VISIT DATE: 11/02/2023
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A sample review of 5 client and 5 staff records was conducted and found to contain required documentation. Facility does not manage client medications or P&I monies. Vehicle inspection and maintenance logs were observed to be kept on a daily basis for all vehicles transporting clients.

At the time of visit, clients were engaged and socially interactive. They participated in music, dance, a lesson on the Solar System, lunch, facility training.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this inspection:

Copy of Current Lease Agreement
Copy of Current Liability Insurance
Resident Roster

No deficiencies found at the time of inspection.
No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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