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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200178
Report Date: 05/27/2022
Date Signed: 05/27/2022 02:12:42 PM

Document Has Been Signed on 05/27/2022 02:12 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:RESIDENCES-BRENTWOOD, THEFACILITY NUMBER:
079200178
ADMINISTRATOR:FERNANDO NESTOR R. UY JR.FACILITY TYPE:
735
ADDRESS:1581 CORNELL DRIVETELEPHONE:
(925) 516-8580
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Nestor Uy, AdministratorTIME COMPLETED:
02:35 PM
NARRATIVE
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On 5/27/2022 at 10:40 AM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with S2. Staff called Administrator Nestor Uy, LPA spoke with Administrator to informed him the purpose of the visit, at 11:35AM, Administrator arrived at the facility. LPA observed 5 clients during the visits, 1 client is not present at the facility. Facility has census of 6.

Facility has a completed mitigation plan. LPA inspected the facility inside and outside. LPA observed insufficient covid19 signage in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is the Administrator. 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. Water temperature was checked, it was observed at 115 degrees Fahrenheit.

Continued on next page LIC 809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
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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Document Has Been Signed on 05/27/2022 02:12 PM - It Cannot Be Edited


Created By: Leslie Ibo On 05/27/2022 at 01:29 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: RESIDENCES-BRENTWOOD, THE
FACILITY NUMBER: 079200178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)(5)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (5) Recognition of early signs of illness and the need for professional assistance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above no proof of covid19 training for all staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
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Administrator agreed to submit copy of covid19 training topic with staff names and siganture by POC date.
Type B
Section Cited
CCR
80076(a)(21)
Food Services
(a) In facilities providing meals to clients, the following shall apply:
(21) Equipment necessary for the storage, preparation and service of food shall be provided, and shall be well-maintained


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 where LPA observed damaged fridge drawer which posed potential health and safety risk to person in care.
POC Due Date: 06/06/2022
Plan of Correction
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Administrator agreed to either replace or fix the broken fridge drawer. Administrator stated that he will send picture to LPA 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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/27/2022 02:12 PM - It Cannot Be Edited


Created By: Leslie Ibo On 05/27/2022 at 01:33 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: RESIDENCES-BRENTWOOD, THE
FACILITY NUMBER: 079200178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.


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 where knives unlocked; toxins were accessible in cabinet located under the sink which posed immediate health, safety risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Cleared. Staff locked knives and toxins during the 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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022


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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: RESIDENCES-BRENTWOOD, THE
FACILITY NUMBER: 079200178
VISIT DATE: 05/27/2022
NARRATIVE
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LPA observed the following:
· Facility DOES NOT document daily COVID-19 symptom checks, and any change in condition for staff and residents in order to track spread and why facility took certain steps to prevent and mitigate spread in the facility.

· LPA recommended to have more covid19 posters in the common areas (to promote hand washing, cough/sneeze etiquette and physical distancing).

· Facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use.(see lic809D)

· Facility DO NOT have adequate 30-day supply of PPE (e.g., facemasks, respirators, gowns, gloves, and eye protection such as face shield or goggles). (technical assistance)

· LPA observed knives unlocked; toxins were accessible in cabinet located under the sink.

· LPA observed fridge drawer is damaged.


Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Nestor Uy.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC809 (FAS) - (06/04)
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