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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200108
Report Date: 06/02/2023
Date Signed: 06/02/2023 04:09:18 PM

Document Has Been Signed on 06/02/2023 04:09 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:
06/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria Reyes, Administrator TIME COMPLETED:
04:15 PM
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On 06/02/23 around 01:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management for a restricted healthcare condition request received on 12/14/22 around 10:35 PM by LPA L. Ibo for Client #1 (C1). LPA met with Maria Reyes, Administrator (ADM), and explained the purpose of the visit.

LPA L. Holmes conducted a joint visit with Program Clinical Consult (PCC), Witnesses (W1, W2), toured the facility with PC, interviewed staff, reviewed records, and observed the compliancy of C1's gastrostomy care.

LPA requested the following documents be submitted to CCLD by 06/09/23: Documentation including, but not limited to C1's gastrostomy care, current physician's report, doctor's orders, appraisal and needs service plan/ISP, dietician referral, hospital discharge summary from 2016, Sutter home health records, staff members training records, and sign-in sheet for training attendees.

PCC determined that further review is needed.

Exit interview conducted and a copy of this report was provided to ADM.



SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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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