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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201094
Report Date: 03/20/2023
Date Signed: 03/20/2023 03:06:00 PM

Document Has Been Signed on 03/20/2023 03:06 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: 12DATE:
03/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Christine Schwab, Program DirectorTIME COMPLETED:
03:20 PM
NARRATIVE
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On 3/20/2023 starting at 2:20PM, Licensing Program Analyst (LPA) L. Ibo conducted a Case Management visit with Program Director Christine Schwab, in relation to the SOC341 received on 3/17/2023, staff inappropriately touched client in care.

During the course of interview, program director admitted that incident happened on 2/3/2023 and she was informed on 2/4/2023, however the incident was not timely reported to CCL not until 3/08/2023 and SOC341 received on 3/17/2023.

Based on interview and records review, S2 inappropriately touched C1 while S2 was cleaning the facility. LPA could not interview S2 since he was terminated from the facility. According to Program Director Christine S. a police report was also filed regarding the incident. LPA did not get a chance to interview C1 since he was not present during LPA’s visit.

Program director will submit the following documents to CCL by 3/23/2023: C1’s physician’s report and IPP. LPA also requested clients schedule and staff schedule for the month of February 2023 – March 2023.

Due to insufficient information at this time, LPA will conduct additional interviews and documents reviews. LPA will return to the facility.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D.

Failure to submit proof of correction (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. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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 03/20/2023 03:06 PM - It Cannot Be Edited


Created By: Leslie Ibo On 03/20/2023 at 02:33 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: 03/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited
CCR
80061(b)(1)(E)

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Reporting Requirements: Upon the occurrence… of any of the events specified…a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report …. shall be submitted to the licensing agency within seven days.......
-This requirement is not met as evidenced by:
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Administrator conducted in-service training for all staff regarding the regulation cited above and submitted proof on 3/31/2023.
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-Based on interview, licensee did not comply with the above Regulation by failing to submit incident reports to CCL which poses potential health, safety and personal right risks to persons in care.
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In addition, administrator will send self-certification that she read the Regulation and ensure reports are submitted within Regulation’s time frame. Proof to be submitted by 3/31/2023

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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: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


LIC809 (FAS) - (06/04)
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