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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201279
Report Date: 09/11/2024
Date Signed: 09/11/2024 01:03:08 PM

Document Has Been Signed on 09/11/2024 01:03 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/
DIRECTOR:		CUMISKEY, MARIAFACILITY TYPE:
735
ADDRESS:4 VISTA DIABLOTELEPHONE:
(650) 346-3874
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 4CENSUS: 2DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Maria Cumiskey, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On 9/11/2024 at 1:25pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. Maria Cumiskey, Administrator arrived at 12:08pm and explained the purpose of the visit. The administrator currently holds a certificate (#7006512735) that expires on 02/08/2026. The facility’s fire clearance was approved for four (4) ambulatory clients. There were not any clients present during visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) bedrooms and two (2) bathrooms. One (1) bedroom used as an office. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 107.0 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 7/31/2024. Emergency disaster plan last updated on 7/1/2024. Fire drill last conducted 8/7/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/11/2024
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Continued from LIC809.

Three (3) staff files and both client files were reviewed, current and complete. LPA reviewed P&I.

The following forms to be updated and submitted to CCLD by 9/18/2024.
  • LIC610D Emergency disaster plan (last page)
  • Surety Bond
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources

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

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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