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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200196
Report Date: 01/31/2024
Date Signed: 01/31/2024 02:27:50 PM

Document Has Been Signed on 01/31/2024 02:27 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: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: 34DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Jechane Reyes, Manager DirectorTIME COMPLETED:
02:35 PM
NARRATIVE
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On 01/31/24 at 12:00pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson arrived unannounced to conduct an Annual 1-year required inspection. LPAs met with Jechane Reyes, Manager Director, and explained the reason for the visit. The facility's fire clearance was approved for 40 ambulatory and 20 non-ambulatory.

LPAs inspected the facility with Program Director, which included but not limited to the bathrooms, kitchen, and common areas of the facility. LPAs observed the facility to be free of odor, clean and in good repair. There is a comfortable room temperature of 70 degrees Fahrenheit for clients in care. Grab bars mats were observed in bathrooms and throughout the facility. Clients bring their own lunches and snacks to facility. The hot water temperature in the shared bathroom measured 90.2 degrees. All observed toilets and hand washing stations are maintained in a safe, sanitary, operating condition. There are no bodies of water or fire safety hazards observed. Carbon monoxide and smoke detectors found to be in working order. Centrally stored medications, toxins and sharp objects were locked and inaccessible to clients. Emergency disaster plan last updated 3/2/2021. Fire extinguisher last services 7/7/2023. Fire drill last conducted 6/21/2023. First aid kit was checked and is complete.

LPAs reviewed five (5) staff files. LPAs reviewed six (6) clients and all were current and complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CISS BRENTWOOD DAY PROGRAM
FACILITY NUMBER: 079200196
VISIT DATE: 01/31/2024
NARRATIVE
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Continued from LIC809.

The following forms to be updated and submitted to CCLD by 2/7/2024:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 610D Emergency Disaster Plan

LPAs observed the following deficiencies:
  • At 12:10pm, LPAs observed during record review S2 and S3 was not associated to the facility.
  • At 1:00pm, LPAs observed during record review S4 and S5 does not have their health screening.


Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/31/2024 02:27 PM - It Cannot Be Edited


Created By: Laura Hall On 01/31/2024 at 02:07 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: CISS BRENTWOOD DAY PROGRAM
FACILITY NUMBER: 079200196

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)(3)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: (3) Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having S2 & S3 associated to day program which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Program Manager associated S2 & S3 during visit. Deficiency cleared.
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/31/2024 02:27 PM - It Cannot Be Edited


Created By: Laura Hall On 01/31/2024 at 02:07 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: CISS BRENTWOOD DAY PROGRAM
FACILITY NUMBER: 079200196

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (10) A health screening, as specified in Section 82065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having S4 and S5 health screening and TB in the personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2024
Plan of Correction
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Program Manager will obtain a copy of the health screening with TB and submit copy to CCLD 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024


LIC809 (FAS) - (06/04)
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