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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201279
Report Date: 02/13/2025
Date Signed: 02/13/2025 11:58:55 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2025 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250207154040
FACILITY NAME:INTERMEZZO ARFFACILITY NUMBER:
079201279
ADMINISTRATOR:CUMISKEY, MARIAFACILITY TYPE:
735
ADDRESS:4 VISTA DIABLOTELEPHONE:
(650) 346-3874
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:4CENSUS: 2DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Maria Cumiskey, AdministratorTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Staff refused to accept resident back at the facility after hospitalization
INVESTIGATION FINDINGS:
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On 2/13/2025 10:25am, Licensing Program Analyst (LPA), L. Hall and arrived unannounced to conduct the 10-day initial visit and conduct complaint investigation for the above allegation. LPA met with Maria Cumiskey, Administrator, and explained the reason for the visit.

During visit LPA interviewed S1, and obtained the following documents for C1: transition planning meeting, dangerous propensities, individual program plan, preplacement appraisal, functional capability, and physician's report. S1 stated during interview that she did accept C1 into the facility on January 23, 2025. S1 stated prior to C1's admission meetings were being held twice a week to prepare for C1 to have an

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20250207154040
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: INTERMEZZO ARF
FACILITY NUMBER: 079201279
VISIT DATE: 02/13/2025
NARRATIVE
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Continued from LIC9099.

easy transition. On January 24, 2025, S1 observed C1 having behaviors that demonstrated C1 required a higher level of care. Facility staff contacted 9-1-1 to assist with C1. C1 was taken to Kaiser. During visit S1 called and spoke with C1's responsible party via telephone with LPA. C1's responsible party stated C1 has returned to his previous facility and will remain there until a higher level of care placement can be found.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC9099D.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250207154040
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: INTERMEZZO ARF
FACILITY NUMBER: 079201279
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2025
Section Cited
CCR
85068.5(a)
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85068.5 Eviction Procedures (a) The licensee shall be permitted to evict a client by serving the client with a 30-day written notice to quit for any of the following reasons:
This requirement was not met as evidence by:
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Administrator agreed to submit self-certification that going forward the facility will follow the eviction process if necessary and submit self-certification to CCLD by POC date.
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Based on interview and record review the Licensee did not comply with the section cited above in following regulation for eviction which poses a potential health and safety risk to person in care.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3