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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200239
Report Date: 12/05/2023
Date Signed: 12/05/2023 04:22:56 PM

Document Has Been Signed on 12/05/2023 04:22 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:RES SUCCESSFACILITY NUMBER:
079200239
ADMINISTRATOR:IAN BREMNERFACILITY TYPE:
775
ADDRESS:702 ALFRED NOBEL DR.TELEPHONE:
(925) 229-8228
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 30CENSUS: 26DATE:
12/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Johana Galean Program ManagerTIME COMPLETED:
04:45 PM
NARRATIVE
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On 12/5/2023 at 2:15pm, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct an Annual 1-year required inspection. LPA met with Johana Galean, Program Manager, and explained the reason for the visit. The facility's fire clearance was approved for 30 ambulatory participants.

LPA inspected the facility with Program Manager, which included but not limited to the bathrooms, kitchen and common areas. LPA observed the facility to be free of odor, clean and in good repair. There is a comfortable room temperature of 77 degrees Fahrenheit for participants in care. Participants bring their own lunches and snacks to facility. 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 fire alarms found to be in working order. Toxins and sharp objects were locked and inaccessible to participants. Fire extinguisher last services 10/19/2023. The last fire drill was conducted on 11/28/2023. First aid kit was checked and is complete.

LPA reviewed four (4) staff files and all have current first aid & CPR certification. LPA reviewed eight (8) participants and all were current and complete.

Deficiencies observed during tour
Paint cans located in the warehouse area
Water temperature was 98.1 and 102.5

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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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Document Has Been Signed on 12/05/2023 04:22 PM - It Cannot Be Edited


Created By: Carol Fowler On 12/05/2023 at 03:48 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: 079200239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having paint cans in the warehouse area accessible to participants in care which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/06/2023
Plan of Correction
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Program Manager had a staff member move and lock the paint cans in storage. Deficiency cleared during visit.
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by maintaining a water temperature less then 105 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/06/2023
Plan of Correction
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Program Manager agreed to have the water heater adjusted and sample water, take a photo and email 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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


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: 079200239
VISIT DATE: 12/05/2023
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Continued from LIC809.

The following forms to be updated and submitted to CCLD by 12/15/2023:

· LIC 308 Designation of Administrative Responsibility
· LIC 610D Emergency Disaster Plan


The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, 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 of this report and appeal rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC809 (FAS) - (06/04)
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