079200920-1-31-2023-15-AS-LIBO-CNLRUN-20230131122013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200920
Report Date: 01/31/2023
Date Signed: 01/31/2023 12:20:34 PM

Document Has Been Signed on 01/31/2023 12:20 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:	CISS PAINT CREATIVE ARTS DAY PROGRAM		FACILITY NUMBER:	079200920
ADMINISTRATOR:	FREITAS, LESLIE		FACILITY TYPE:	775
ADDRESS:	8335 BRENTWOOD BLVD STE F		TELEPHONE:	(925) 666-8142
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY: 30		CENSUS: 26	DATE:	01/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Leslie Freitas, Administrator		TIME COMPLETED:	12:35 PM

NARRATIVE

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On 01/31/2023, Licensing Program Analyst (LPA), L. Ibo arrived announced to conduct an infection control annual inspection. LPA met Administrator Leslie Freitas; LPA explained the purpose of the visit. Facility has census of 26. LPA observed clients at the facility conducting different types of activities with staff assisting the clients in care.

LPA toured the program with Administrator, Leslie Freitas, including but not limited to the bathrooms and common area. LPA observed the facility to be free of odor, clean and in good repair. Outdoor space is provided and is free of hazards. Clients bring their own lunch, however for instances that clients do not bring their lunch then the program can provide snacks for them. Toilets and hand washing stations are maintained in a safe, sanitary, operating condition. There are no bodies of water or fire safety hazards observed during visit. Indoor and outdoor passageways were kept free of obstruction.

There was an enough supply of toiletry supplies & PPE supplies. There are locked cabinets available to store medications. The facility is equipped with fire extinguishers, smoke detectors, carbon monoxide detectors and a complete first aid kit.

...Continue to LIC809C...

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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: CISS PAINT CREATIVE ARTS DAY PROGRAM	FACILITY NUMBER: 079200920
	VISIT DATE: 01/31/2023

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LPA observed the following:

1. Facility needs to document covid19 screening for staff, clients, and visitors. LPA requested a copy of the new screening form before facility implement it.

2. At 10:13AM LPA observed unlocked cabinet where the disinfectant supplies are stored.

3. Facility staff failed to conduct a routine symptom screening (+/- temperature and symptom check) at entry and for all staff, clients, and visitors.

Technical violation:

1. Administrator failed to comply with licensing laws and regulation, this is particularly for covid19 guidelines. LPA strongly recommend to have the Administrator review adult day program PINS on CCLD website. An attestation letter needs to be submitted to LPA by 02/10/2023. Attestation letter should also includes Provided information notices (PINs) that the Administrator reviewed.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Leslie Freitas.

Exit interview conducted and a copy of this report provided. A copy of appeal rights was provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/31/2023 12:20 PM - It Cannot Be Edited

Created By: Leslie Ibo On 01/31/2023 at 11:50 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: CISS PAINT CREATIVE ARTS DAY PROGRAM	FACILITY NUMBER: 079200920
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2023

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
1 2 3 4	Based on observation the licensee did not comply with the section cited above that at 10:13AM LPA observed unlocked cabinet where the disinfectant supplies are stored, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2023
	Plan of Correction
1 2 3 4	Cleared during the visit . Administrator agreed to retrain staff on the regulation cited above, a copy of training with staff names and signature need to be submitted to LPA by 2/10/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Leslie Ibo

LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC809 (FAS) - (06/04)

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