<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200178
Report Date: 03/25/2025
Date Signed: 03/26/2025 06:05:10 PM

Document Has Been Signed on 03/26/2025 06:05 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:RESIDENCES-BRENTWOOD, THEFACILITY NUMBER:
079200178
ADMINISTRATOR/
DIRECTOR:		FERNANDO NESTOR R. UY JR.FACILITY TYPE:
735
ADDRESS:1581 CORNELL DRIVETELEPHONE:
(925) 516-8580
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 5DATE:
03/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Emerita De Jesus, Direct Care StaffTIME VISIT/
INSPECTION COMPLETED:
03:53 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03/25/2025 at 9:50AM, Licensing Program Analysts (LPAs) T. Syess-Gibson and Y. Brown conducted an unannounced annual 1-Year required inspection. LPAs met with Emerita De Jesus, Caregiver, and explained the purpose of the visit. Emerita advised LPAs that administrator Fernando Uy Jr is out of town. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPAs toured the facility with Caregiver, Emerita including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of six (6) total bedrooms and three (3) bathrooms. Two (2) bedrooms used by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 degrees Fahrenheit. LPAs 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 120.9 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/20/2025. Emergency Disaster Plan was last posted on 05/29/2024. Fire drill conducted on 02/03/2025. First aid kit was observed to be complete.

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
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)
Page: 2 of 8
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: RESIDENCES-BRENTWOOD, THE
FACILITY NUMBER: 079200178
VISIT DATE: 03/25/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809.

LPAs reviewed five (5) clients records and four (4) staff records, three (3) out of four (4) staff are missing FirstAid/CPR. LPAs also reviewed P & I and a sample of medication

LPA requested the following documents to be submitted to CCLD by 04/01/2025.

  • Surety Bond
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • LIC400 (Affidavit Regarding Client/Resident Cash Resources)
  • LIC610D (Emergency Disaster Plan)
  • Updated Facility Sketch

Continue on LIC809C

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

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
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: RESIDENCES-BRENTWOOD, THE
FACILITY NUMBER: 079200178
VISIT DATE: 03/25/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809C

LPA observed the following deficiencies:

  • At 10:48AM LPAs observed window and back door screens in disrepair
  • At 10:51AM LPAs observed an unlocked kitchen cabinet drawer with three lighters and a pair of scissors
  • At 11:01AM LPAs observed medication in an unlocked cabinet in the kitchen.
  • At 11:05AM LPAs observed an unlocked garage with Behr paint and primer, charcoal lighter fluid, EZ patch spackling compound, Burnout weed and grass killer, Sliper Tech engine oil, Peak Antifreeze and coolant, Oreck allergen control carpet cleaner and Real Kill indoor fogger.

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,LIC421FC and this report provided

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

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 03/26/2025 06:05 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 03/25/2025 at 02:26 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: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087 Buildings and Grounds
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having Behr paint and primer, charcoal lighter fluid, EZ patch spackling compound, Burnout weed and grass killer, Sliper Tech engine oil, Peak Antifreeze and coolant, Oreck allergen control carpet cleaner and Real Kill indoor fogger.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
1
2
3
4
Care staff immediately locked Disinfectants, cleaning solutions, poisons and other items .Deficiency cleared during visit.
Type A
Section Cited
CCR
80075(k)(1)
80075 Health Related Services
(k)The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having medications in a kitchen cabinet with a broken lock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
1
2
3
4
Care staff immediately removed medications and placed in a locked cabinet. Deficiency cleared during the visit.
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: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 03/26/2025 06:05 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 03/25/2025 at 02:31 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: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
80088 Furniture, Fixtures, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having window and backdoor screens are in disrepair which poses an immediate health, safety or personal rights risk to persons in care..
POC Due Date: 04/01/2025
Plan of Correction
1
2
3
4
Administrator agreed to repair or replaced screens and send CCLD a photo email of repair by POC date.
Type B
Section Cited
CCR
85604(b)
85064 Administrator Qualifications and Duties
(b) All adult residential facilities shall have a certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in not having a current administrator certificate posted or in personnel file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2025
Plan of Correction
1
2
3
4
Administrator agreed to send a copy of current Administrator Certificate 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 03/26/2025 06:05 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 03/25/2025 at 02:34 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: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(3)
0019 Criminal Record Clearance
e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(3) Request a transfer of a criminal record clearance as specified in Section 80019 (f) or


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having S2 and S4 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2025
Plan of Correction
1
2
3
4
Administrator agreed to associated S2 and S4 or submit S2 and S4’s LIC9182 and a copy of their identification to have S2 and S4 associated to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
Page: 8 of 8