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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600385
Report Date: 06/03/2025
Date Signed: 06/03/2025 01:36:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2025 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20250602095755
FACILITY NAME:COMMUNITY INTEGRATED WORK PROGRAMFACILITY NUMBER:
075600385
ADMINISTRATOR:MONICA CARDOZAFACILITY TYPE:
775
ADDRESS:1105 BUCHANAN ROAD, SUITE ATELEPHONE:
(925) 778-2905
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:48CENSUS: 6DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Monica Cardoza, Program DirectorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Facility restroom is in disrepair
INVESTIGATION FINDINGS:
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On 6/3/2025 at 12:00pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegation above. LPA met with Monica Cardoza, Program Director, and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with W1, staff, toured bathroom and outside back area.

Allegation: Facility restroom is in disrepair.

Based on interview witness was told about bathroom being in disrepair and pictures were submitted. LPA toured both the men and women bathroom and observed one

Continued on LIC9099C.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20250602095755
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: COMMUNITY INTEGRATED WORK PROGRAM
FACILITY NUMBER: 075600385
VISIT DATE: 06/03/2025
NARRATIVE
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Continued from LIC9099.

tank top in the women's bathroom and the tank top in men's bathroom missing. In the women's bathroom there were holes in the wall behind the door. The urinal was missing from the men's bathroom, but the hole hasn't been repaired. S1 stated the urinal was removed in January. The tank tops were also removed in January, however, there is someone that is trying to remake the tank tops. S1 had an estimate to repair the holes in the bathroom wall.

LPA obtained estimate for bathroom.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250602095755
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COMMUNITY INTEGRATED WORK PROGRAM
FACILITY NUMBER: 075600385
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2025
Section Cited
CCR
82087(a)
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82087 Buildings and Grounds (a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidence by:
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Program Director agreed to replace toilets in order to obtain new tank tops, repair holes in women's bathroom, and close wall where urinal was removed, and submit photos to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having both bathrooms in repair which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3