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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200108
Report Date: 11/26/2024
Date Signed: 11/26/2024 03:32:40 PM

Document Has Been Signed on 11/26/2024 03:32 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CICADA - BRENTWOODFACILITY NUMBER:
079200108
ADMINISTRATOR/
DIRECTOR:		MARIA LIRA REYESFACILITY TYPE:
735
ADDRESS:1175 MULBERRY PLACETELEPHONE:
(925) 513-8437
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:38 AM
MET WITH:Clairinda Bonkingki, Caregiver TIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On 11/26/2024 at 10:38 AM, Licensing Program Analyst (LPA) T.Syess-Gibson arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Clairinda Bongkingki and explained the purpose of the visit. Clairinda contacted Administrator, Maria Lira Reyes via telephone and explained purpose of the visit. The facility’s fire clearance was approved for six (6) non ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of five (5) total bedrooms which four (4) bedrooms are occupied by the clients and one (1) bedroom is occupied by staff located in the garage. All outdoor and indoor passageways are kept free of obstruction. LPA observed a pool behind a locked gate in the backyard. A comfortable temperature for clients is maintained at 70- 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 135.8-degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene’s were available for clients. There is a minimum of one week supply of nonperishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/29/2024. Emergency Disaster Drill was last posted on 12/08/2023. First aid kit was observed to be complete. Fire drill was last conducted on 05/05/2024.


Continue on LIC809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CICADA - BRENTWOOD
FACILITY NUMBER: 079200108
VISIT DATE: 11/26/2024
NARRATIVE
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Continued LIC809

Five (5) clients’ records was reviewed. Five (5) staff records were reviewed, and four (4) out of five (5) have current first aid training. LPA reviewed P&I and a sample of medication during visit.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/03/2024.

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan

LPA observed the following deficiencies:

· At 10:57AM, LPA observed during tour of facility in the kitchen area gnats.
· At 10:58AM, LPA observed during tour of facility broken kitchen faucet.
· At 11:16AM, LPA observed during tour of facility one (1) closet door and two(2) out four (4) chest of drawers in clients' rooms were in disrepair.
· At 11:19AM, LPA observed during tour of facility water temperatures measured at 135.8 degrees F in the common restroom.
· At 11:23AM, LPA observed during tour of facility unlocked cabinets in the laundry room with the following items; Clorox bleach, wood oil cleaner, fabuloso multipurpose cleaner, dishwasher pods/packs, bathroom rust and stain remover, laundry detergent and windex.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
Exit interview conducted. A copy the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 11/26/2024 03:32 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 11/26/2024 at 02:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CICADA - BRENTWOOD
FACILITY NUMBER: 079200108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having gnats in the kitchen near the fruit which poses potential health risk to persons in care.
POC Due Date: 12/03/2024
Plan of Correction
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Administrator agreed to rewash fruits and purchase a trap to get rid of the gnats/fruit flies. Administrator will send email with photos and proof of purchase to CCLD by POC date.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not maintaining water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). which poses a potential health, safety risk to persons in care.
POC Due Date: 12/03/2024
Plan of Correction
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Administrator agreed to adjust water temperature to 105 - 120 degrees F and submit photo to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 11/26/2024 03:32 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 11/26/2024 at 03:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CICADA - BRENTWOOD
FACILITY NUMBER: 079200108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having broken closet door, broken chest of drawers in clients' rooms and broken faucet in the kitchen which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/03/2024
Plan of Correction
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Administrator agreed to send photos of repaired or replaced items to CLLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/26/2024 03:32 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 11/26/2024 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CICADA - BRENTWOOD
FACILITY NUMBER: 079200108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having disinfectants, cleaning solutions and other items accessible to clients which posed an immediate health and safety risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Caregiver immediately locked cabinets with the above items. Deficiency cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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