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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600385
Report Date: 04/02/2024
Date Signed: 04/02/2024 12:05:52 PM

Document Has Been Signed on 04/02/2024 12:05 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: 11DATE:
04/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Lowelyn Santamaria, Program CoordinatorTIME COMPLETED:
12:15 PM
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On 4/2/2024 at 10:05am, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 3/13/2024 and an amended incident report on 3/27/2024. LPA met with Lowelyn Santamaria, Program Coordinator and explained the purpose of the visit.

S1 submitted an incident report for staff misconduct that occurred on 3/8/2024, however, facility was not notified about the misconduct until 3/12/2024. S1 stated that C1's home administrator notified the day program about the misconduct and the day program conducted an internal investigation. S2 was suspended pending investigation on 3/14/2024 and terminated on 3/18/2024.

LPAs collected the following documents: client roster, staff roster, C1's emergency sheet, admission agreement, individual program plan (IPP), semi annual report. S2's employment application, staff information sheet, adverse action notification, employee suspension, employee separation, service agendas.

LPA requested the following documents to be submitted to CCLD by end of day 4/3/2024: Facility's investigation of misconduct.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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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