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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601508
Report Date: 08/18/2022
Date Signed: 08/18/2022 04:17:48 PM


Document Has Been Signed on 08/18/2022 04:17 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:COGIR OF BRENTWOODFACILITY NUMBER:
075601508
ADMINISTRATOR:MARTINO, AMANDAFACILITY TYPE:
740
ADDRESS:150 CORTONA WAYTELEPHONE:
(925) 240-0733
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:150CENSUS: 98DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Kuldip Singh, Wellness nurseTIME COMPLETED:
04:35 PM
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On 8/18/2022 at 3:00 PM, Licensing Program Analyst (LPA) L. Ibo conducted an infection control annual inspection and explained the purpose of the visit with Kuldip Singh, facility nurse. Facility has census of 98. New administrator Amanda Martino arrived around 4:10PM.

Facility has a completed mitigation plan. LPA requested a copy of infection control plan to be sent by 8/22/2022. LPA acknowledged receiving a copy of monkey pox infection control plan. LPA inspected the facility inside and outside. Pathways were observed to be free of obstruction and fire hazards. Facility has a pool located at south side of the building.

Infection control designated leader is Kuldip Singh (nurse) and Michael Carchidi (maintenance manager). There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 73 degrees Fahrenheit. A certified Administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.

...continued to LIC809C..
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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: COGIR OF BRENTWOOD
FACILITY NUMBER: 075601508
VISIT DATE: 08/18/2022
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LPA observed the following:

Facility is using accushield to conduct covid19 screening, based on interview there is a system glitch “sometime” this week, it is only screening for temperature, however it stopped asking for covid19 questions. Wellness nurse Kuldip Singh stated that facility will start using manual covid19 screening for all staff, residents and visitors. (technical assistance provided)

Facility needs to add more covid19 posters in the common areas of the facility. Technical assistance was provided.

Signs need to be posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect residents from infection during pandemic, in accordance with personal rights requirements.

No deficiency cited during the visit. Exit interview conducted with Kuldip Singh and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC809 (FAS) - (06/04)
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