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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200959
Report Date: 02/10/2023
Date Signed: 02/10/2023 11:23:46 AM

Document Has Been Signed on 02/10/2023 11:23 AM - 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:WORKING WONDERSFACILITY NUMBER:
079200959
ADMINISTRATOR:SCHWAB, CHRISTINEFACILITY TYPE:
775
ADDRESS:315 ORCHARD DRTELEPHONE:
(925) 331-7797
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 8CENSUS: 6DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Yvonne Rivera, staff on duty TIME COMPLETED:
11:45 AM
NARRATIVE
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On 02/10/2023 at 9:25AM, Licensing Program Analyst (LPA) L. Ibo arrived announced to conduct an infection control annual inspection. LPA met with S3 and informed her the purpose of the visit. LPA called Administrator and informed her the purpose of the visit. Administrator stated that reports can be given and read to the facility staff on duty.

LPA L. Ibo toured facility with S2. LPA inspected the facility inside and outside including but not limited to common areas, outdoor area and 2 bathrooms. Covid19 screening are being conducted upon entrance, but facility is not documenting covid19 symptoms. LPA provided technical assistance and discussed with Christine S. that all covid19 screening for staff, clients and visitors are needed to be documented. Facility is clean and in good repair. Smoke detector and carbon monoxide detector are interconnected to the building. First aid kit is complete. Clients bring their own lunch/snacks, but facility have available emergency snacks for clients in case that clients doesn’t bring their own food.

LPA observed the following:

· S4 is not associated at the facility.

· At 9:38AM LPA observed that storage closet for disinfectants and cleaning products are unlock and accessible to clients in care.

· Licensee failed to provide proof of covid19 training for all staff.

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 S2, and Administrator was also informed.


Exit interview conducted and appeal rights copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 02/10/2023 11:23 AM - It Cannot Be Edited


Created By: Leslie Ibo On 02/10/2023 at 11:00 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: WORKING WONDERS
FACILITY NUMBER: 079200959

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023

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
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Based on observation the licensee did not comply with the section cited above in licensee failed to lock the disinfectant closet where all disinfectant and cleaning products were stored, this was accesible to clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Cleared and corrected during visit. Staff locked the disinfectant closet.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/10/2023 11:23 AM - It Cannot Be Edited


Created By: Leslie Ibo On 02/10/2023 at 11:00 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: WORKING WONDERS
FACILITY NUMBER: 079200959

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065(f)(5)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (5) Recognition of early signs of illness and the need for professional assistance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interview , licensee failed to provide proof of covid19 training for all staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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Licensee will send proof of covid19 training for all staff to CCL by POC date.
Type B
Section Cited
CCR
82019(e)(2)
Criminal Record Clearance
(e) Prior to working, residing or volunteering 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: (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

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in licensee failed to associate S4 to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2023
Plan of Correction
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Licensee/ Administrator agreed to associate S4 to facility by POC date. Proof of association needs to be submitted to LPA 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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023


LIC809 (FAS) - (06/04)
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