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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200959
Report Date: 03/15/2024
Date Signed: 03/15/2024 12:58:32 PM

Document Has Been Signed on 03/15/2024 12:58 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:WORKING WONDERSFACILITY NUMBER:
079200959
ADMINISTRATOR:SCHWAB, CHRISTINEFACILITY TYPE:
775
ADDRESS:315 ORCHARD DRTELEPHONE:
(925) 331-7797
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 8CENSUS: 5DATE:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rosa Ramos SupervisorTIME COMPLETED:
01:05 PM
NARRATIVE
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On 03/15/2024 at 9:45 AM, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson arrived unannounced to conduct an Annual 1-year required inspection. LPAs met with Rosa Ramos, Supervisor, and explained the reason for the visit. The facility's fire clearance was approved for 8 ambulatory.

LPAs inspected the facility with Supervisor, which included but not limited to the bathrooms, kitchen, back yard, 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 73 degrees Fahrenheit for clients in care. Clients bring their own lunches and snacks to facility. The hot water temperature in the shared bathroom measured 118.3 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 07/24/2023. Fire extinguisher last services 11/01/2022. Fire drill last conducted 08/10/2023. First aid kit was checked and is complete.

LPAs reviewed two (2) staff files and two (2) staff files weren't available for review. LPAs reviewed six (6) clients and all were missing Appraisal Needs and Service Plan.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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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Document Has Been Signed on 03/15/2024 12:58 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 03/15/2024 at 11:28 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: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82072(a)(6)(7)
82072 Personal Rights
(a) Each client shall have personal rights which include, but are not limited to, the following:
(6) To leave or depart the day program at any time.
7) Not to be locked in any room, building, or day program site.

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 having an emergency exit gate locked with pad lock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2024
Plan of Correction
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Program Supervisor immediately removed the lock during visit. Deficiency cleared during visit.
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024


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: WORKING WONDERS
FACILITY NUMBER: 079200959
VISIT DATE: 03/15/2024
NARRATIVE
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Continued from LIC809.

The following forms to be updated and submitted to CCLD by 03/22/2024:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 (Updated)
  • LIC 610D Emergency Disaster Plan (last page)

LPAs observed the following deficiencies:
  • At 9:58am, LPAs observed during tour of facility an emergency exit gate locked with pad.
  • At 10:54am LPAs observed during record review that two (2) staff files weren't available for review.


*The total amount of civil penalties assessed on today's date is $500.00 for fire exit gate being locked.*

Deficiency is 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: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/15/2024 12:58 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 03/15/2024 at 12:00 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: WORKING WONDERS
FACILITY NUMBER: 079200959

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(c)
Personnel Records
(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

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 innot having all staff files available for review. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Program Supervisor agreed to submit self certification to CCLD that all staff files will be availble for review at the facility by POC date.
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024


LIC809 (FAS) - (06/04)
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