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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200012
Report Date: 05/23/2022
Date Signed: 05/23/2022 02:51:59 PM

Document Has Been Signed on 05/23/2022 02:51 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 SUPPORT SERVICESFACILITY NUMBER:
079200012
ADMINISTRATOR:ANGELA HAGUEFACILITY TYPE:
775
ADDRESS:1600 A STREETTELEPHONE:
(925) 777-0696
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 30CENSUS: 29DATE:
05/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jechane Reyes, Director of OperationsTIME COMPLETED:
02:55 PM
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On 5/23/2022 at 2:00PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Jechane Reyes, Director of Operations, and explained the purpose of the visit.

Upon entry, LPA's temperature was checked. LPA observed screening station that contained hand sanitizer and sign-in log. LPA toured facility including but not limited to common areas and bathrooms. All hand washing stations were equipped with soap, and paper towel, and hand washing poster. Hot water temperature in the shared clients’ bathroom was measured at 105.1 degrees Fahrenheit. There were not any clients present during visit.

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

The following forms are to be updated and submitted to CCLD by 5/30/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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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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 SUPPORT SERVICES
FACILITY NUMBER: 079200012
VISIT DATE: 05/23/2022
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Continued from LIC809.

-LIC610D Emergency Disaster Plan

No deficiencies cited during visit.

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

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
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