347004390-5-26-2021-27-AS-TTRG-C3DPD5-20210526111259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004390
Report Date: 05/26/2021
Date Signed: 05/26/2021 11:13:05 AM

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:	UNIQUE ABILITIES MONTESSORI ADP, LLC		FACILITY NUMBER:	347004390
ADMINISTRATOR:	NORMAN-YUSUF, AR'TANYA		FACILITY TYPE:	775
ADDRESS:	1831 V STREET		TELEPHONE:	(916) 730-5884
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95818
CAPACITY:	30	CENSUS: 0	DATE:	05/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Tali Yusuf, Licensee		TIME COMPLETED:	11:30 AM

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	Licensing Program Analysts (LPAs) Avelina Martinez and Tung Truong arrived at this facility unannounced on 05/26/2021 at 9:00 AM to conduct an annual inspection visit. LPAs met with Licensee Taliatu Yusuf and explained the purpose of the visit. Licensee Taliatu Yusuf holds current certificate # 6012093735 and expires on 12/2/2020. Administrator Artanya Yusuf holds current certificate # 6049976735 and expires on 2/15/2020. The Licensee will designate a temporary administrator and provide the documents to LPA Truong. Licensee will provide to LPA Truong proof of registered courses and designation of a temporary administrator by 5/27/2021. The licensee and administrator is in the process of renewing their certificate. The facility is licensed for 30 ambulatory adult/elderly developmentally disabled clients. Ages 18 and over. There are currently no clients and staff attending at this day program. The day program is currently temporary closed due to COVID-19. The licensee stated he plan to resume operating in July. The LPA's toured the facility with the Licensee Taliatu Yusuf on 05/26/2021 at 9:15 AM. LPA's inspected the physical plant including but not limited to the office, class rooms, kitchen, dining room, resident bathrooms, game room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA's also conducted the infection control domain tool. Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: UNIQUE ABILITIES MONTESSORI ADP, LLC	FACILITY NUMBER: 347004390
	VISIT DATE: 05/26/2021

NARRATIVE

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The facility common areas were furnished and sanitary. The facility has a public telephone, and the facility has implemented virtual visits and outside visits. The facility has Covid-19 posting throughout the facility. The facility has submitted a mitigation plan to CCLD and was approved. The facility has one central entry point, and the facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented.

The facility water temperature is 110 degrees. The facility class rooms are furnished and sanitary. Facility bathrooms are sanitary. Smoke and carbon detectors are up to date. Fire extinguishers are up to date. The exterior emergency exit door is clear of derbies. The facility first aid kit is up to date. Facility files are up to date. The following documents were requested:

-Personnel Report (LIC 500)
-Emergency Disaster Plan
-Qualification of Administrator
-Designation of Administrative Responsibility. (LIC 308)

Per California Code of Regulations, Title 22, no deficiencies were cited during this visit.

Exit interview was held and a report was given to Taliatu Yusuf.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

LIC809 (FAS) - (06/04)

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