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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600385
Report Date: 12/11/2024
Date Signed: 12/11/2024 02:26:32 PM

Document Has Been Signed on 12/11/2024 02:26 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: DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Lorena Garay, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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On 12/14/2024 at 12:10pm, Licensing Program Analyst (LPA) L. Hall, arrived unannounced to conduct an annual required inspection. LPA met with Lorena Garay, Program Director, and explained the reason for the visit. The facility's fire clearance was approved for 38 ambulatory and 10 non-ambulatory.

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 72 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 113.7 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 11/5/2024. Fire drill last conducted 9/17/2024. First aid kit was checked and is complete.

LPA reviewed five (5) staff and four (4) clients' records.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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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: 12/11/2024
NARRATIVE
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Continued from LIC809.

The following forms to be updated and submitted to CCLD by 12/18/2024:
  • LIC 610D Emergency Disaster Plan
  • LIC 308 Designation of facility Responsibility
  • At 1:35pm, LPA observed during record review that none of the clients' has an appraisal needs and services plan.


Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. 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: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2024 02:26 PM - It Cannot Be Edited


Created By: Laura Hall On 12/11/2024 at 02:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COMMUNITY INTEGRATED WORK PROGRAM
FACILITY NUMBER: 075600385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary, but at least annually, to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental, psychological, and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having and appraisal needs and services plan for each client which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Program Director agreed to complete an appraisal needs and services plan for each client and submit a self-certification to CCLD that it has been done by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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