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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200920
Report Date: 02/02/2024
Date Signed: 02/02/2024 12:21:11 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/02/2024 12:21 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 PROGRAMFACILITY NUMBER:
079200920
ADMINISTRATOR:FREITAS, LESLIEFACILITY TYPE:
775
ADDRESS:8335 BRENTWOOD BLVD STE FTELEPHONE:
(925) 666-8142
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 30CENSUS: 24DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jeremy Riley, Direct Care SupportTIME COMPLETED:
12:30 PM
NARRATIVE
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On 02/2/24 at 10:00am, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson arrived unannounced to conduct an Annual 1-year required inspection. LPAs met with Jeremy Riley, Direct Care Support, and explained the reason for the visit. Jechane Reyes, Manager Director arrived at 10:25am. The facility's fire clearance was approved for 25 ambulatory and 5 non-ambulatory.

LPAs inspected the facility with Program Director, which included but not limited to the bathrooms, kitchen, and common areas of the facility. LPAs observed the facility to be free of odor, clean and in good repair. There is a comfortable room temperature of 67 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 87 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. Emergency disaster plan last updated 09/30/2022. Fire extinguisher last services 08/08/2019. Fire drill last conducted 01/03/2024. First aid kit was checked and is complete.


LPAs reviewed seven (7) staff files. LPAs reviewed six (6) clients.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
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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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: 02/02/2024
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Continued from LIC809.

The following forms to be updated and submitted to CCLD by 2/16/2024:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 610D Emergency Disaster Plan

LPAs observed the following deficiencies:
  • At 10:25am, LPAs observed during record review S2, S3, S4 and S5 was not associated to the facility.
  • At 11:15am LPAs observed water temperature in shared bathroom at 87 degrees.


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

DATE: 02/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/02/2024 12:21 PM - It Cannot Be Edited


Created By: Laura Hall On 02/02/2024 at 12:03 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: 02/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2024
Section Cited
CCR
82019(e)(2)

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82019 Criminal Record Clearance
(e) Prior to working... in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: This requirement was not met as evidence by:


(2) Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f); or
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Managing Director associated S2, S3, S4, and S5 immediatley. Deficiency cleared during visit.
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Based on LPAs observation and record review the Licensee did not comply with the section cited above in having S2, S3, S4, and S5 associated to the facility which poses a potential health and safety risk to persons in care.
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Type A
02/03/2024
Section Cited
CCR82088(e)(1)

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82088 (e) Faucets used by clients for personal care shall deliver hot water. (1) Hot water temperature controls shall be maintained to... a hot water temperature of not less than 105 degrees F and not more than 120 degrees F
This requirement was not met as evidence:
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Managing Director adjusted hot water temperature to108 during visit. Deficiency cleared during visit.
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Based on observation the Licensee did not comply with the section cited above in have water temperature between 105 - 120, which poses a potential health and safety risk to persons in care.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


LIC809 (FAS) - (06/04)
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