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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200108
Report Date: 12/09/2022
Date Signed: 12/09/2022 03:50:39 PM

Document Has Been Signed on 12/09/2022 03:50 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:CICADA - BRENTWOODFACILITY NUMBER:
079200108
ADMINISTRATOR:MARIA LIRA REYESFACILITY TYPE:
735
ADDRESS:1175 MULBERRY PLACETELEPHONE:
(925) 513-8437
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lira Reyes, Administrator TIME COMPLETED:
04:10 PM
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On 12/9/2022 at 2:30PM, Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an infection control annual inspection. LPA met with Administrator Lira Reyes. Facility has census of 6.

LPA toured the facility with staff on duty (S2) including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. LPA observed there is a backyard swimming pool surrounded by a locked fence. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Visitors policy is posted on the front entrance. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days. Smoke detectors and carbon monoxide were in operating condition during visit.

Facility has enough supplies of PPEs, paper supplies and hygiene supplies. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

LPA and Administrator discussed about to start G-tube exception request for C1.

No deficiency cited during the visit.

Exit interview conducted. Copy of this report provided.


SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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