<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200012
Report Date: 03/14/2025
Date Signed: 03/14/2025 12:24:58 PM

Document Has Been Signed on 03/14/2025 12:24 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:		REYES, JECHANEFACILITY TYPE:
775
ADDRESS:1600 A STREETTELEPHONE:
(925) 777-0696
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 30CENSUS: 22DATE:
03/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Mary Jane Mejia, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03/14/2025 at 10:20am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an 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 109.6 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 4/25/2024. Fire extinguisher last services 4/22/2024. Fire drill last conducted 2/25/2025. First aid kit was checked and is complete.

LPA reviewed five (5) staff files. LPA reviewed six (6) clients none had an appraisal needs and services plan.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 03/14/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809.

The following forms to be updated and submitted to CCLD by 3/21/2025:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 610D Emergency Disaster Plan (last page)
  • LIC500 Personnel record


LPA observed the following deficiencies.
  • At 11:05am, LPA observed during record review S3 did not have a health screening.
  • At 11:25am, LPA observed during record review none of the clients had an appraisal needs and services plan.


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 and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/14/2025 12:24 PM - It Cannot Be Edited


Created By: Laura Hall On 03/14/2025 at 12:11 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: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (10) A health screening, as specified in Section 82065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in S3 having a health screen and TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2025
Plan of Correction
1
2
3
4
Program Manager agreed to have S3 obtain a health screening and TB test, and submit form to CCLD by POC date.
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having a appraisal needs and service paln for participants which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2025
Plan of Correction
1
2
3
4
Program Manager agreed to obtain a appraisal needs and services plan for all participants and submit a self-certification that it has been done 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: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2025


LIC809 (FAS) - (06/04)
Page: 3 of 3