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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 01:52:10 PM

Document Has Been Signed on 04/09/2024 01:52 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Fabiola De La Torre, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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On 4/9/2024 at 1:15pm, Licensing Program Analyst (LPA) L. Hall and conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 4/5/2024. LPA met with Fabiola De La Torre, Program Manager and explained the purpose of the visit.

S1 submitted an incident report for a client's misconduct that occurred on 4/3/2024. The incident report indicated that C1 had said things of a sexual nature to C2. C1 was suspended on 4/4/2024, pending the interdisciplinary team meeting (IDT). S1 stated the IDT meeting will held on 4/9/2024 and will include C1 and his parents, case manager, and day program staff. During the meeting C1 was offered to attend another location. The IDT meeting was held and it was decided that C1 will not longer attend the day program.

LPA collected the following documents: client roster, staff roster, C1's admission agreement and individual program plan (IPP).

No deficiencies issued during the visit.

Exit interview conducted and a copy of 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
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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