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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200239
Report Date: 10/02/2024
Date Signed: 10/02/2024 01:12:38 PM

Document Has Been Signed on 10/02/2024 01:12 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/
DIRECTOR:		IAN BREMNERFACILITY TYPE:
775
ADDRESS:702 ALFRED NOBEL DR.TELEPHONE:
(925) 229-8228
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 30CENSUS: 22DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Sheila Savannah, Direct Care ProfessionalTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 10/02/2024 at 9:50am, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct an Annual 1-year required inspection. LPA met with Sheila Savannah, Direct Care Professional and explained the reason for the visit. The facility's fire clearance was approved for 30 ambulatory participants.

LPA inspected the facility with Direct Care Professional, 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 76 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 09/20/2024. First aid kit was checked and is complete.

LPA reviewed four (4) staff files and all have current first aid & CPR certification. LPA reviewed seven (7) participants and all INCOMPLETE.


Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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Document Has Been Signed on 10/02/2024 01:12 PM - It Cannot Be Edited


Created By: Carol Fowler On 10/02/2024 at 12:36 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: 10/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 having water temperature 132.2 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/03/2024
Plan of Correction
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Manager agreed to correct and maintain water temperature to read between 105 and 120 degrees F and submit a video of the water temperature to the department by the POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2024 01:12 PM - It Cannot Be Edited


Created By: Carol Fowler On 10/02/2024 at 12:36 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: 10/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(3) All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in day programs accommodating physically handicapped clients who need such items.

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 a slow draining sink in bathroom #1 which poses a potential health and safety risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Manager agreed to have a pluming company or facility handyman fix the drainage issue and submit a video of sink draining by the POC date.
Type B
Section Cited
CCR
82068.2(f)(1)(B)
Needs and Services Plan
(f) The completed Needs and Services Plan shall include: (1) The client's desires and background and formal supports, obtained from the client's family or his/her authorized representative, if any, regarding the following: (B) A written medical assessment including primary physician, health problems and medical history, prescribed medications and their strength, quantity, frequency required and purpose as specified in Section 82069(b)(3).

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 incomplet and out dated documents in participant files which poses a potential health and safety risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Manager agreed to read and understan the regulation self certify and update/complete participants files and submit a sample to the department by the 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: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


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: 10/02/2024
NARRATIVE
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continued from LIC 809

Deficiencies observed during tour
At 11:15AM LPA observed a slow drain in bathroom #1.
At 11:18AM LPA observed water temperature in second bathroom is 132.2 degrees Fahrenheit.
At 12:30PM LPA observed participant files are incomplete

The following forms to be updated and submitted to CCLD by 10/09/2024:

· 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: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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