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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200212
Report Date: 04/09/2024
Date Signed: 04/09/2024 01:46:05 PM

Document Has Been Signed on 04/09/2024 01:46 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:RES SUCCESSFACILITY NUMBER:
079200212
ADMINISTRATOR/
DIRECTOR:		FABIOLA DELA TORREFACILITY TYPE:
775
ADDRESS:2980 RAILROAD AVENUETELEPHONE:
(925) 473-9552
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 72CENSUS: 47DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Kenya Criss, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 4/9/2024 at 09:35AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Annual 1-year required inspection. LPA met with Kenya Criss, Program Manager for downstairs and then met with Fabiola De La Torre, Program Manager for upstairs. Facility is fire cleared for seventy-two (72) ambulatory clients.

LPA inspected the facility with Program Directors, which included but not limited to the bathrooms, kitchen, common areas, and the outside area of the facility. LPA observed the facility to be free of odor, clean and in good repair. Outdoor space is provided and is free of hazards. There is a comfortable room temperature of 72 degrees Fahrenheit for clients in care. Grab bars and non-skid mats were observed in bathrooms and throughout the facility. Clients bring their own lunches and snacks to facility. The hot water temperature in the client bathroom measured 115.9 degrees Fahrenheit upstairs and 116.8 degrees Fahrenheit downstairs. 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 1/9/2024. Fire extinguisher last services 8/2/2023. Fire drill last conducted 3/27/2024. First aid kit was checked and is complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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: RES SUCCESS
FACILITY NUMBER: 079200212
VISIT DATE: 04/09/2024
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Continued from LIC809.

LPA reviewed ten (10) client files reviewed, current, and complete. Nine (9) staff files were reviewed, current and complete. LPA reviewed P & I and a sample of medication.

The following forms to be updated and submitted to CCLD by 04/16/2024:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 610D Emergency Disaster Plan (last page)
  • Surety Bond
  • Affidavit regarding client cash resources

LPA observed the following deficiency:
  • At 11:10am, LPA observed during record review that S7 was not associated to the facility.


*An immediate $500.00 civil penalty will be assessed on today's date for staff not being associated.*

Exit interview conducted. A copy of LIC421BG, appeal rights, and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/09/2024 01:46 PM - It Cannot Be Edited


Created By: Laura Hall On 04/09/2024 at 01:03 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: RES SUCCESS
FACILITY NUMBER: 079200212

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)(3)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: (3) Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having S7 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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Licensee immediately associated S7 to the facility. Deficiency cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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