<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201274
Report Date: 07/31/2024
Date Signed: 07/31/2024 04:55:35 PM

Document Has Been Signed on 07/31/2024 04:55 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:RES SUCCESSFACILITY NUMBER:
079201274
ADMINISTRATOR/
DIRECTOR:		BREMNER, IANFACILITY TYPE:
775
ADDRESS:3490 BUSKIRK AVETELEPHONE:
(925) 363-9705
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94553
CAPACITY: 45CENSUS: 36DATE:
07/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Teanna Jerkins, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/31/2024 at 12:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Program Manager, Teanna Jerkins and explained the purpose of the visit. Day program operates from 9:30 AM to 3:30 PM. There were 2 staff observed working with the 34 (thirty-four) clients here today. There were 2 (two) clients that participates via Zoom.

LPA toured facility with Teanna including but not limited to, multiple activity rooms, kitchen, bathrooms, office space, and the outside recreational area. Clients bring their own lunches and snacks. Emergency supplies, including water were observed. The hot water temperature in the client bathrooms measured 126 and 131 degrees Fahrenheit. Cleaning supplies are locked and inaccessible to clients. Medications are not handled/dispensed by this program. There are no bodies of water or fire safety hazards observed. Restrooms are maintained in safe and in sanitary operating condition. The program has 1 van used for client outings, and was observed to be clean. Van maintenance oil change log was reviewed and maintained 03/11/2024. LPA reviewed client and staff files for sampling. Emergency disaster drills are conducted on a monthly basis. Fire extinguishers throughout facility were last inspected 12/10/2023. First aid kit was checked.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.


LIC809-D Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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 7
Document Has Been Signed on 07/31/2024 04:55 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 07/31/2024 at 04:25 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: RES SUCCESS
FACILITY NUMBER: 079201274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in by not having the hot water temperature lowered between 105-120 degrees which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
1
2
3
4
By POC date, Administrator will send a photo to CCLD of adjusted hot water temperature.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 07/31/2024 04:55 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 07/31/2024 at 04:25 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: RES SUCCESS
FACILITY NUMBER: 079201274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065.1(d)(1)
Personnel Qualifications and Duties
(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by having all Direct Support Staff training updated in their files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
1
2
3
4
BY POC date, Administrator will submit to CCLD staff transcripts of updated training.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: RES SUCCESS
FACILITY NUMBER: 079201274
VISIT DATE: 07/31/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LIC809-C Continued...

The following forms to be updated and submitted to CCL by 08/07/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 610 Emergency Disaster Plan - Reviewed

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7