079200037-11-25-2025-15-AS-LAWN-DNRU8T-20251125142206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200037
Report Date: 11/25/2025
Date Signed: 11/25/2025 02:22:32 PM

Document Has Been Signed on 11/25/2025 02:22 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	RESIDENTIAL & EDUCATIONAL SERVICES		FACILITY NUMBER:	079200037
ADMINISTRATOR/ DIRECTOR:	DILLON VARIZ		FACILITY TYPE:	775
ADDRESS:	620 LAS JUNTAS		TELEPHONE:	(925) 957-1665
CITY:	MARTINEZ	STATE: CA	ZIP CODE:	94553
CAPACITY: 20		CENSUS: 17	DATE:	11/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:40 AM
MET WITH:	Dillon Variz, Program Manager		TIME VISIT/ INSPECTION COMPLETED:	02:45 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 11/25/2025 at 10:40 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Assistant Manager, Amanda Montoya, and explained the purpose of the visit. Amanda called Program Manager, Dillon Variz, to inform. Dillon arrived shortly after. Day program operates from 9:00 AM to 4:00 PM. There were six (6) staff observed working with the seventeen (17) clients here today. LPA toured facility with Dillon including but not limited to, multiple activity rooms, kitchen, bathrooms, office space, and the outside recreational area. Clients bring their own lunches and snacks. Emergency supplies, including water were observed. The hot water temperature in the client bathroom measured 110 degrees Fahrenheit. Cleaning supplies are locked and inaccessible to clients. Medications are not handled/dispensed by this program. There are no bodies of water or fire safety hazards observed. Restrooms are maintained in safe and in sanitary operating condition, and additional equipment for the physically handicapped was observed. Incontinent clients are kept clean and dry, and the facility is free of odors. The program has one (1) van used for client outings. Reviewed client and staff files for sampling. Emergency disaster drills are conducted on a weekly basis at different times by each instructor. Fire extinguishers throughout facility were last inspected 10/22/2025. First aid kit was checked. LIC809-C Continued...

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 11/25/2025 02:22 PM - It Cannot Be Edited

Created By: Lori Alexander-Washington On 11/25/2025 at 01:39 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: RESIDENTIAL & EDUCATIONAL SERVICES	FACILITY NUMBER: 079200037
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82065.1(d)(1)

Personnel Qualifications and Duties

(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having annual training on file for Direct Support Professional, S6, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2026
	Plan of Correction
1 2 3 4	Administrator agreed to submit S6 annual training to CCLD by POC due date. Repeat Violation Civil Penalty $250.00

Type B

Section Cited

CCR

82068(a)

Admission Agreements

(a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having an admission agreement on file for P1 and P4 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/07/2026
	Plan of Correction
1 2 3 4	Administrator agreed to submit copies of admission agreements for P1 and P4 to CCLD by POC due date. Repeat Violation Civil Penalty $250.00

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:

	Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/25/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/25/2025 02:22 PM - It Cannot Be Edited

Created By: Lori Alexander-Washington On 11/25/2025 at 01:39 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: RESIDENTIAL & EDUCATIONAL SERVICES	FACILITY NUMBER: 079200037
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82069(b)(1)

Client Medical Assessments

(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having medical assessment with a negative TB result for P4 on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/07/2026
	Plan of Correction
1 2 3 4	Administrator agreed to submit a copy of medical assessment with TB result for P4 to CCLD by POC due date. Repeat Violation Civil Penalty $250.00

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

	Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:

	Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/25/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: RESIDENTIAL & EDUCATIONAL SERVICES	FACILITY NUMBER: 079200037
	VISIT DATE: 11/25/2025

NARRATIVE

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LIC809-C (Page 2)

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/02/2025:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources - Reviewed
LIC 402 Surety Bond - Reviewed
LIC 500 Personnel Report -
LIC 610D Emergency Disaster Plan (Page 9) - Reviewed
Copy Liability Insurance Certificate

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Program Manager, Dillon Variz. Appeal Rights, LIC421FCs and a copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025

LIC809 (FAS) - (06/04)

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