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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200012
Report Date: 04/22/2024
Date Signed: 04/22/2024 01:02:55 PM

Document Has Been Signed on 04/22/2024 01:02 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/
DIRECTOR:		ANGELA HAGUEFACILITY TYPE:
775
ADDRESS:1600 A STREETTELEPHONE:
(925) 777-0696
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 30CENSUS: 24DATE:
04/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Mary Jane Mejia, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 04/22/2024 at 10:05am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Annual 1-year required inspection. LPA met with Mary Jane Mejia, Program Manager, and explained the reason for the visit. The facility's fire clearance was approved for 30 ambulatory.

LPA inspected the facility with Program Manager, which included but not limited to the bathrooms, kitchen, outside area, and common areas of the facility. LPAs observed the facility to be free of odor, clean and in good repair. There is a comfortable room temperature of 70 degrees Fahrenheit for clients in care. Grab bars mats 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 102.8 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. Centrally stored medications, toxins and sharp objects were locked and inaccessible to clients. Emergency disaster plan last updated 6/5/2022. Fire extinguisher last services 6/2/2022. Fire drill last conducted 4/15/2024. First aid kit was checked and is complete.

LPAs reviewed five (5) staff files. LPAs reviewed six (6) clients.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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 SUPPORT SERVICES
FACILITY NUMBER: 079200012
VISIT DATE: 04/22/2024
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Continued from LIC809.

The following forms to be updated and submitted to CCLD by 4/29/2024:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 610D Emergency Disaster Plan (9 pages)
  • LIC400 Administrative organization
  • LIC500 Personnel record


LPA observed the following deficiencies.
  • 11:20am, LPA observed fire extinguishers have not been services since 6/2/2022.
  • At 11:35am, LPA observed both exit gates were locked with chain and padlock.
  • At 11:30am, LPA observed facility have conducted alterations inside building.


*An immediate $500.00 civil penalty will be assessed today for locked gates*

Deficiencies are 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 the appeal rights, LIC421M, and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2024 01:02 PM - It Cannot Be Edited


Created By: Laura Hall On 04/22/2024 at 12:38 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 SUPPORT SERVICES
FACILITY NUMBER: 079200012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82072(a)(7)
82072 Personal Rights
(a) Each client shall have personal rights which include, but are not limited to, the following:
(7) Not to be locked in any room, building, or day program site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having emergency exit gates locked with padlock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
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Program Manager removed padlocks on both gates. Deficiency cleared immediately.
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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4
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: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/22/2024 01:02 PM - It Cannot Be Edited


Created By: Laura Hall On 04/22/2024 at 12:42 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 SUPPORT SERVICES
FACILITY NUMBER: 079200012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82020
82020 Fire Clearance

All day programs shall secure through the licensing agency and maintain a fire clearance approved by the city or county fire department, the district providing
fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having fire extinguisher serviced which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
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Program Manager will have fire extinguisher services and submit photo or invoice of updated service.
Type B
Section Cited
CCR
82086(a)
82086 Alterations to Existing Buildings or New Facilities

(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in notifying CCLD of proposed alterations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
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Program Manager will submit LIC200 and updated facility sketch to CCLD by POC date.
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: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


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