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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201094
Report Date: 09/08/2022
Date Signed: 09/08/2022 01:38:07 PM

Document Has Been Signed on 09/08/2022 01:38 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:WORKING WONDERSFACILITY NUMBER:
079201094
ADMINISTRATOR:SCHWAB, CHRISTINEFACILITY TYPE:
775
ADDRESS:150 MIDDLEFIELD CT SUITE FTELEPHONE:
(925) 331-7797
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 24CENSUS: 18DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:CHRISTINE SCHWAB, Administrator TIME COMPLETED:
02:00 PM
NARRATIVE
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On 9/8/2022 at 11:50 AM, Licensing Program Analyst (LPA), L. Ibo arrived announced to conduct an infection control annual inspection. LPA met with S2; Administrator Christine Schwab arrived around 12:00 noon. Facility has census of 18.

LPA L. Ibo toured facility with S2. LPA inspected the facility inside including but not limited to, isolation room, common areas, computer area, and 2 bathrooms. There is a loft area on the back of the facility that is inaccessible to clients. Clients are using the back-door area to enter the facility. Covid19 screening are being conducted upon entrance but facility is not documenting covid19 symptoms or temperature. 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:

· S2 is not associated at the facility. Citation was cleared during the visit.

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 Christine Schwab, Administrator.



Exit interview conducted and appeal rights copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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 09/08/2022 01:38 PM - It Cannot Be Edited


Created By: Leslie Ibo On 09/08/2022 at 01:05 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: 079201094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f)....


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in licensee failed to associate or transfer criminal records clearance of S2 prior to working at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2022
Plan of Correction
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Administrator sent copy of LIC9182, copy of S2's ID and LIC508 to Oakland Regional office to process the transfer.
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: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022


LIC809 (FAS) - (06/04)
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