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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200920
Report Date: 12/30/2024
Date Signed: 12/30/2024 03:03:46 PM

Document Has Been Signed on 12/30/2024 03:03 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CISS PAINT CREATIVE ARTS DAY PROGRAMFACILITY NUMBER:
079200920
ADMINISTRATOR/
DIRECTOR:		SHAWN CRANEFACILITY TYPE:
775
ADDRESS:8335 BRENTWOOD BLVD STE FTELEPHONE:
(925) 666-8142
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 30CENSUS: 24DATE:
12/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Shawn Crane, Day Program ManagerTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 12/30/2024 at 11:25am, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct an Annual 1-Year required inspection. LPA met with Shawn Crane, Program Manager, and explained the reason for the visit. Jechane Reyes, Manager Director arrived at 11:40am. The facility's fire clearance was approved for 25 ambulatory and 5 non-ambulatory clients.

LPA inspected the facility with Program Manager, which included but not limited to the bathrooms, kitchen, and common areas of the facility. LPA observed the facility to be free of odor, clean and in good repair. There is a comfortable room temperature of 70 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 117.0 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. Toxins and sharp objects were locked and inaccessible to clients. Emergency disaster plan last updated 07/09/2024. Fire extinguisher last services 02/02/2024. Fire drill last conducted 11/06/2024. First aid kit was checked and is complete.

Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CISS PAINT CREATIVE ARTS DAY PROGRAM
FACILITY NUMBER: 079200920
VISIT DATE: 12/30/2024
NARRATIVE
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Continued from LIC809.

LPA reviewed six (6) staff files, three(3) out of six (6) staff members were missing a minimum of eight (8) hours a year of training. LPA also reviewed six (6) clients' files, three (3) out of six (6) clients were missing Physician Reports.

The following forms to be updated and submitted to CCLD by 01/06/2025:

· LIC 308 Designation of Administrative Responsibility
· LIC 610D Emergency Disaster Plan (9 pages)


LPA observed the following deficiencies:

· At 12:54pm, LPA observed during record review three (3) out of six (6) clients were missing Physician Reports.
· At 1:22pm, LPA observed during record review direct care staff S3, S4, S5 and S6 did not receive and complete a minimum of eight (8) hours a year of documented training.


Exit interview conducted. A copy of the appeal rights and this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC809 (FAS) - (06/04)
Page: 11 of 17
Document Has Been Signed on 12/30/2024 03:03 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 12/30/2024 at 02:13 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: CISS PAINT CREATIVE ARTS DAY PROGRAM
FACILITY NUMBER: 079200920

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065.1(d)(1)
Personnel Qualifications and Duties
(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
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
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
Page: 12 of 17
Document Has Been Signed on 12/30/2024 03:03 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 12/30/2024 at 02:15 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: CISS PAINT CREATIVE ARTS DAY PROGRAM
FACILITY NUMBER: 079200920

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065.1(d)(1)
Personnel Qualifications and Duties
(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
82068.2(f)(1)(B)
Needs and Services Plan
(f) The completed Needs and Services Plan shall include: (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: (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
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
Page: 14 of 17
Document Has Been Signed on 12/30/2024 03:03 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 12/30/2024 at 02:22 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: CISS PAINT CREATIVE ARTS DAY PROGRAM
FACILITY NUMBER: 079200920

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(f)(1)(B)
82068.2 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, the client’s family or their 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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in three(3) out of six (6) clients are missing medical assessments. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2025
Plan of Correction
1
2
3
4
Program Director agreed to submit a self certifying email to CCLD indicating all clients in care has a medical assessment placed in their files by POC date.
Type B
Section Cited
CCR
82065.1(d)(1)
82065.1 Personnel Qualifications and Duties
(d) The licensee shall develop,maintain, and implement a written plan for the orientation, continuing education, on-the-job training and
development, supervision, and evaluation of all direct care staff.
(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not having four (4) out of six (6) direct care staff members receiving a minimum of 8 hours of training, documented which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2025
Plan of Correction
1
2
3
4
Program Director agreed to send a self certifying email to CCLD of all direct care staff members completed and documented 8 hours minimum of training 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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
Page: 16 of 17
Document Has Been Signed on 12/30/2024 03:03 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 12/30/2024 at 02:47 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: CISS PAINT CREATIVE ARTS DAY PROGRAM
FACILITY NUMBER: 079200920

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(f)(1)(B)
82068.2 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, the client’s family or their 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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not having (3) out of (6) clients' medical assessments which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2025
Plan of Correction
1
2
3
4
Program Director agreed to obtain all clients in care medical assessments and place copies in their files. Program Director also agreed to send CCLD a self certifying email by POC date.
Type B
Section Cited
CCR
82065.1(d)(1)
82065.1 Personnel Qualifications and Duties
(d) The licensee shall develop,maintain, and implement a written plan for the orientation, continuing education, on-the-job training and
development, supervision, and evaluation of all direct care staff.
(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not having (4) out of (6) direct care staff receiving a minimum of 8 hours a year of training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2025
Plan of Correction
1
2
3
4
Program Director agreed to have all direct care staff complete a minimum of 8 hours of training, documented and place in their files. Program Director will send a self certifying 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
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