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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200196
Report Date: 01/14/2025
Date Signed: 01/14/2025 03:37:06 PM

Document Has Been Signed on 01/14/2025 03:37 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:CISS BRENTWOOD DAY PROGRAMFACILITY NUMBER:
079200196
ADMINISTRATOR/
DIRECTOR:		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:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:57 PM
MET WITH:Jechane Reyes, Manager Director TIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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On 01/14/2025 at 1:57PM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct an Annual 1-Year required inspection. LPA 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 clients.

LPA inspected the facility with Manager Director, which included but not limited to the bathrooms, kitchen, and common areas of both units (E & F) of facility. LPA observed the facility to be free of odor, clean and in good repair. There is a comfortable room temperature of 72 degrees Fahrenheit for clients in care. Grab bars 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 105.0 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. Toxins and sharp objects were locked and inaccessible to clients. Emergency disaster plan last updated 12/31/2024. Fire extinguisher last services 07/07/2023 Fire drill last conducted 12/05/2024 First aid kit was checked and is complete.

Continued on LIC809C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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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: CISS BRENTWOOD DAY PROGRAM
FACILITY NUMBER: 079200196
VISIT DATE: 01/14/2025
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Continued from LIC809.

LPA reviewed five (5) staff record , and all staff have first aid certification and associated to facility. LPA reviewed five (5) clients' records they were current, and complete.

The following forms to be updated and submitted to CCLD by 01/21/2025:

· LIC 308 Designation of Administrative Responsibility
· LIC 610D Emergency Disaster Plan (9 pages)


No deficiencies were sited during this inspection


Exit interview conducted and a copy of this report provided Jeanette Alarcon.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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