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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600385
Report Date: 11/30/2022
Date Signed: 11/30/2022 01:20:25 PM

Document Has Been Signed on 11/30/2022 01:20 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 3DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Monica Cardoza, Program DirectorTIME COMPLETED:
01:25 PM
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On 11/30/2022 at 12:30AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Monica Cardoza, Program Director, and explained the purpose of the visit.

Upon entry, LPA's temperature was checked. LPA observed screening station at entrance that contained hand sanitizer and sign-in log. LPA toured facility including but not limited to common areas, bathrooms, and kitchens. All hand washing stations were equipped with soap, and paper towel, and hand washing poster. Fire extinguishers last serviced 11/04/2022. Hot water temperature measured at 139.1 degrees F.

During record review, LPA observed facility has a copy of the Mitigation Plan on file. LPA observed PPE and paper supplies are sufficient.

The following forms are to be updated and submitted to CCLD by 12/7/2022:
  • Infection Control Plan (LIC9283)

No deficiencies cited during visit.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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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