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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200108
Report Date: 12/02/2025
Date Signed: 12/02/2025 05:49:37 PM

Document Has Been Signed on 12/02/2025 05:49 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: 5DATE:
12/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:02 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 12/02/2025 at 3:02PM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Angeline Acupan, Staff, and explained the purpose of the visit. Angeline 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) bedrooms ,one (1) bedroom is occupied by staff located in the garage and two (2) bathrooms. 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 66 degrees Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 137.7 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene’s was available for clients. There is a minimum of 7-day supply of nonperishables and 2-day perishables food supply.

Continue on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 12/02/2025
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Continued LIC809

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/10/2025. Emergency Disaster Drill was last posted on 05/31/2025. First aid kit was observed to be complete. Fire drill was last conducted on 05/30/2025.

Four (4) clients’ records were reviewed, four (4) staff records were reviewed, and they were all complete. LPA was not able to review P&I during visit, Administrator stated P&I was at other licensed facility.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/09/2025.

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

Continue on LIC809C.....

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
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: 12/02/2025
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Continued from LIC809C

LPA observed the following deficiencies:

  • At 3:36PM, LPA observed during tour of facility water temperatures measured at 137.7 degrees F in the common restroom.
  • At 4:16PM, LPA observed during record review client’s cash resources were not at the facility for review.

Deficiencies are 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. Appeal rights and a copy of this report provided to Angeline Acupan.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2025 05:49 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 12/02/2025 at 05:20 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: 12/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(3)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(3) The licensee shall provide access to the cash resources upon demand by the client or his/her authorized representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not having client's cash resources accessible upon demand which poses a personal rights risk to persons in care.
POC Due Date: 12/09/2025
Plan of Correction
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Administrator agreed to implement a plan regarding providing access to cash resources upon demand. Administrator will send CCLD an email of the plan by POC date.
Type B
Section Cited
CCR
80088(e)(1)
(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 having hot water temperature at 137.7 degrees F which poses safety risk to persons in care.
POC Due Date: 12/09/2025
Plan of Correction
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Administrator agreed to implement a plan to maintain hot temperature not less than 105 degrees F and not more than 120 degrees F. Administrator will send CCLD an email of the plan 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


LIC809 (FAS) - (06/04)
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