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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600385
Report Date: 06/14/2024
Date Signed: 06/14/2024 02:01:09 PM

Document Has Been Signed on 06/14/2024 02:01 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/
DIRECTOR:		MONICA CARDOZAFACILITY TYPE:
775
ADDRESS:1105 BUCHANAN ROAD, SUITE ATELEPHONE:
(925) 778-2905
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 48CENSUS: 6DATE:
06/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Monica Cordoza, DirectorTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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On 6/14/2024, at 1:30pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 6/11/2024. LPA met with Monica Cordoza, Director, and explained the purpose of the visit.

S1 submitted an incident report for a client that was left unsupervised on 6/10/2024. S1 stated S2 was aware that C1 had went to the bathroom, and S2 kept walking with two (2) other clients. When C1 came out of the bathroom he did not see S2 or the facility van and thought they had left. The facility had previously conducted an in-service training regarding supervision on May 21, 2024, with all staff. The facility conducted an internal investigation and terminated S2.

LPA L. Hall obtained an amended incident report dated 6/12/2024 and a copy of S2's termination letter.

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: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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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