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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200012
Report Date: 09/21/2023
Date Signed: 09/21/2023 01:09:15 PM

Document Has Been Signed on 09/21/2023 01:09 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: 21DATE:
09/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Delaney Wells, Program ManagerTIME COMPLETED:
01:20 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 9/21/2023 at 12:20pm, Licensing Program Analysts (LPAs) L. Hall and A. Gomez, conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 9/15/2023. LPA met with Delaney Well, Program Manager, and explained the purpose of the visit.

Incident report for C1 was sent on 9/15/2023 and occurred on 9/12/2023 when C1 AWOL'ed. Program Manager stated during interview that C1 was found by the Antioch Police Department approximately 20 minutes after AWOL. C1 was then taking to the emergency room to get checked out. A police report was not taken. During the visit the facility was having an interdisciplinary team (IDT) meeting for C1.

The deficiency were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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 2
Document Has Been Signed on 09/21/2023 01:09 PM - It Cannot Be Edited


Created By: Laura Hall On 09/21/2023 at 12:46 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: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2023
Section Cited
CCR
80072(a)(2)

1
2
3
4
5
6
7
80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
1
2
3
4
5
6
7
Program Manager agreed to implement a plan to insure AWOL's doesn't occur and submit plan to CCLD by POC date.
8
9
10
11
12
13
14
Based on LPAs interviews and record review the Licensee did not comply with the section cited above in keeping client safe, which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2