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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200563
Report Date: 11/29/2023
Date Signed: 11/29/2023 01:24:03 PM

Document Has Been Signed on 11/29/2023 01:24 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:MISSION-HOPE DAY PROGRAM-ANTIOCHFACILITY NUMBER:
079200563
ADMINISTRATOR:GAMEZ, JUANITA NIMFA YFACILITY TYPE:
775
ADDRESS:10 SOUTH LAKE DRIVETELEPHONE:
(925) 706-7517
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 49CENSUS: 33DATE:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Mitzi Wardini, Program DirectorTIME COMPLETED:
01:25 PM
NARRATIVE
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On 11/29/2023 at 9:40am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Annual 1-year required inspection. LPA met with Mitzi Wardini, Program Director, and explained the reason for the visit.

LPA inspected the facility with Program Director, 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 mats were observed in bathrooms and throughout the facility. Clients bring their own lunches and snacks to facility. The hot water temperature in the shared bathroom measured 127.9 degrees. 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. Fire extinguisher last services 11/9/2023. Fire drill last conducted 8/29/2023. First aid kit was checked and is complete.

LPA reviewed six (6) staff files and all are complete. LPA reviewed eleven (11) clients and none have an appraisal needs and services plan, and four (4) of eleven (11) did not have a physician's report.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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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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: MISSION-HOPE DAY PROGRAM-ANTIOCH
FACILITY NUMBER: 079200563
VISIT DATE: 11/29/2023
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Continued from LIC809.

The following forms to be updated and submitted to CCLD by 12/6/2023:
  • LIC 308 Designation of Administrative Responsibility

The following deficiencies were observed:
  • At 11:40am, LPA observed C1, C2, C3, and C4 did not have a physician's report (LIC602) in their file.
  • At 11:40am, LPA observed none of the client files reviewed contained an appraisal needs and services plan.


Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. 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 the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/29/2023 01:24 PM - It Cannot Be Edited


Created By: Laura Hall On 11/29/2023 at 12:45 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: MISSION-HOPE DAY PROGRAM-ANTIOCH
FACILITY NUMBER: 079200563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary, but at least annually, to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental, psychological, and/or social functioning.

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 an appraisal needs and services plan for each client which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Program Director agreed to complete an appraisal needs and services plan for each client and submit a self-certification that they have been completed to CCLD by POC date.
Type B
Section Cited
CCR
82070(b)(8)
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. A separate, complete, and current record shall be maintained at the program site for each client.

(b) Each record must contain information including, but not limited to, the following:
(8) Medical assessment, including ambulatory status, as specified in Section 82069(b).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having a physician's report on file for C1, C2, C3, and C4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Program Director agreed to obtain a physician's report for C1, C2, C3, and C4 and submit a copy 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


LIC809 (FAS) - (06/04)
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