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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201279
Report Date: 09/06/2023
Date Signed: 09/06/2023 01:57:49 PM

Document Has Been Signed on 09/06/2023 01:57 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:INTERMEZZO ARFFACILITY NUMBER:
079201279
ADMINISTRATOR:CUMISKEY, MARIAFACILITY TYPE:
735
ADDRESS:4 VISTA DIABLOTELEPHONE:
(650) 346-3874
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 4CENSUS: 0DATE:
09/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Maria Cumiskey, LicenseeTIME COMPLETED:
02:05 PM
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On 09/06/2023 at 1:10pm, Licensing Program Analysts (LPAs) L. Hall and A. Gomez, conducted an announced pre-licensing visit. LPAs met with Licensee, Maria Cumiskey, and explained the purpose of the visit. LPA observed no clients were present at the facility during visit. The facility has a fire clearance approved for four (4) ambulatory clients.

LPAs inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage and back yard. The facility has a total of three (3) bedrooms, two (2) bathrooms. There were no bodies of water present during inspection. There is sufficient lighting around the facility. Clients rooms are equipped with the proper furniture, bedding, and lighting. Passageways and hallways are free of obstruction. Locked cabinets available to store medications, toxins, and sharps. Hot water temperature is measured at 105.1 degrees Fahrenheit. Fire extinguisher was last services on 07/15/2022. There is a minimum of 7-day non-perishables and 2-day perishables foods. Carbon monoxide/smoke detectors present. First-Aid kit complete.

Licensing Program Manager H. Humpal approved waiver for COMP III.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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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