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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200196
Report Date: 01/20/2023
Date Signed: 01/20/2023 11:08:58 AM

Document Has Been Signed on 01/20/2023 11:08 AM - 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:CISS BRENTWOOD DAY PROGRAMFACILITY NUMBER:
079200196
ADMINISTRATOR:KELLY THOMPSONFACILITY TYPE:
775
ADDRESS:151 SAND CREEK RD,BLD 6,UN E&FTELEPHONE:
(925) 382-8818
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 60CENSUS: 29DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jeanette Alarcon, Administrator TIME COMPLETED:
11:20 AM
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On 01/20/2023 at 9:45 AM, Licensing Program Analyst (LPA), L. Ibo arrived announced to conduct an infection control annual inspection. LPA met Administrator Jeanette Alarcon; LPA explained the purpose of the visit. Facility has census of 29. LPA did not observe any clients during the visit, according to facility staff, clients are out with other staff doing activities (bowling and shopping).

LPA toured the program with Administrator, Jeanette Alarcon including but not limited to the bathroom, common area, and washing station. LPA observed the facility to be free of odor, clean and in good repair. Outdoor space is provided and is free of hazards. Clients bring their own lunch, however for instances that clients does not bring their lunch then the program can provide snacks for them. Toilets and hand washing stations are maintained in a safe, sanitary, operating condition. There are no bodies of water or fire safety hazards observed during visit. Indoor and outdoor passageways were kept free of obstruction. Cleaning supplies were locked in a cabinet.

There was an enough supply of toiletry supplies & PPE supplies. There are locked cabinets available to store toxins and medications. The facility is equipped with fire extinguishers, smoke detectors, carbon monoxide detectors and a complete first aid kit.

LPA observed the following and technical assistance provided to Administrator:

1. Facility needs to revise covid19 screening and add covid19 questions on the screening form. LPA requested a copy of the new screening form before facility implement it.

No deficiency cited during the visit. Exit interview conducted with Administrator. Copy of this report provided

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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