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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200239
Report Date: 08/13/2024
Date Signed: 08/13/2024 12:43:31 PM

Document Has Been Signed on 08/13/2024 12:43 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: 15DATE:
08/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:JOHANNA GALVAN, PROGRAM MANAGERTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 8/13/2024 at 10:00 AM Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to open a 10 day Complaint Investigation. LPA met with Johanna Galvan, Program Manager and Matthew Hammons, Assistant Program Manager.

When LPA Carol Fowler arrived to open complaint (15-AS-20240808112140) on 8/13/2024, the supply closet which contains cleaning supplies (chemicals) was propped open unsupervised with three (3) cans of BEHR paint.

During complaint investigation. The following was observed:

- On 8/13/2024, supply closet which contains cleaning supplies (chemicals)was propped open unsupervised by three (3) cans of BEHR paint.

The deficiencies was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies 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: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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 08/13/2024 12:43 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/13/2024 at 11:58 AM
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: 08/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2024
Section Cited
CCR
82087(a)(3)

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(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.

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Program Manager agreed to read understand the regulations and conduct in-service with all staff and submit sign in sheet to the Department by the POC date.
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(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.
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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: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


LIC809 (FAS) - (06/04)
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