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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600385
Report Date: 12/14/2023
Date Signed: 12/14/2023 04:50:07 PM

Document Has Been Signed on 12/14/2023 04:50 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: 14DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Monica Cardoza, Program DirectorTIME COMPLETED:
05:00 PM
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On 12/14/2023 at 1:45pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson, arrived unannounced to conduct an Annual 1-year required inspection. LPAs met with Monica Cardova, Director, and explained the reason for the visit. The facility's fire clearance was approved for 38 ambulatory and 10 non-ambulatory. No clients present during inspection.

LPA inspected the facility which included but not limited to the bathrooms, kitchen, common areas, and the outside area of the facility. LPA observed the facility to be free of odor, clean and in good repair. Outdoor space is provided and is free of hazards. There is a comfortable room temperature of 73 degrees Fahrenheit for clients in care. Grab bars were observed in bathrooms and throughout the facility. Clients bring their own lunches and snacks to facility. The hot water temperature in the shared bathroom measured 111.6 degrees. All observed toilets and hand washing stations are maintained in a safe, sanitary, operating condition. There are no bodies of water or fire safety hazards observed. Carbon monoxide and smoke detectors found to be in working order. Sharp objects were locked and inaccessible to clients. Fire extinguisher last services 11/3/2023. Fire drill last conducted 9/19/2023. First aid kit was checked and is complete.

LPA reviewed seven (7) staff files and six (6) clients' files.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: COMMUNITY INTEGRATED WORK PROGRAM
FACILITY NUMBER: 075600385
VISIT DATE: 12/14/2023
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Continued from LIC809.

The following forms to be updated and submitted to CCLD by 12/22/2023:
  • LIC 610D Emergency Disaster Plan

No deficiencies were cited during this inspection.

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

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC809 (FAS) - (06/04)
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