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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200220
Report Date: 09/15/2021
Date Signed: 09/15/2021 03:44:24 PM

Document Has Been Signed on 09/15/2021 03:44 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:GARDEN BRENTWOODFACILITY NUMBER:
079200220
ADMINISTRATOR:JACKIE BAILEYFACILITY TYPE:
775
ADDRESS:1191 CENTRAL BLVD., STE. BTELEPHONE:
(925) 626-3642
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 30CENSUS: 10DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Ciara Vasquez & Annette WinnTIME COMPLETED:
03:30 PM
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On 9/15/2021 at 9:50 AM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with Ciara Vasquez Program Coordinator and Annette Winn, Support Supervisor. The facility has an office, staff room, two restrooms, a large activity room, a separate smaller activity area, a rest area, 3 changing rooms, a kitchenette area (clients bring their lunch and snacks), and a sensory room. LPA observed all areas within the program to be clean, safe, sanitary and in good repair. The facility is equipped with adequate furnishings and equipment to meet client's needs. Medications are kept inaccessible to clients. The facility is equipped with fire extinguishers, smoke and carbon monoxide detectors and complete first aid kit. Pathways were observed to be free of obstruction and fire hazards.


Infection control designated leader is Ciara Vasquez. Facility is using online system to conduct Covid19 screening for staffs, clients and visitors.


Continued on next page LIC 809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2021
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: GARDEN BRENTWOOD
FACILITY NUMBER: 079200220
VISIT DATE: 09/15/2021
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LPA observed the following:
  • The staff (4) and (3) clients from facility Alive east county (075600047) are using Garden Brentwood facility without informing CCL Oakland Regional office.
  • 7 staff are not associated to the facility ( S1, S2, S4, S9, S10, S11 & S12 )
  • 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 provided, proof of correction need to be submitted to LPA on or before 9/27/2021.
  • Since there is inadequate PPE supplies to be stored in local location , there is no PPE stored in a location that is readily accessible to staff.
  • Garden Brentwood changed the plan of operation without informing CCL Oakland regional office.
  • Staff are not FIT tested for N95 per Program Coordinator. LPA reminded program coordinator regarding FIT testing and to review PIN 21-09 and PIN 21-10.

LPA observed that there are 3 clients from Alive East County 075600047 at the facility, LPA interviewed S2, per S2 they’ve been using Garden Brentwood facility for a month now. Alive East County no longer have a their own building. LPA conducted records review, on March 15, 2021, based on welfare call conducted, it was reported that the facility facility lease was not renewed as of November 30, 2020.


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.

LPA issued civil penalty during the visit.

Deficiencies and plan and proof of corrections were discussed with Ciara Vasquez & Annette Winn.

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

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2021 03:44 PM - It Cannot Be Edited


Created By: Leslie Ibo On 09/15/2021 at 02:15 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: GARDEN BRENTWOOD
FACILITY NUMBER: 079200220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)(2)
... All individuals subject to a criminal record review pursuant to Health and Safety Code ...shall do the following: Request the licensee or applicant for a license to request a transfer of a criminal record ...



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation , interview & record review, the licensee did not comply with the section cited above the staff are not associated to the facility ( S1, S2, S4, S9, S10, S11 & S12 ) which poses an immediate health, safety risk to persons in care.
CIVIL PENALTIES ASSESSED $3,500.00
POC Due Date: 09/15/2021
Plan of Correction
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Program coordinator and HR agreed to associate staff (S1, S2, S4, S9, S10, S11 & S12) using guardian system on POC date.
Type A
Section Cited
CCR
82022(g)
Any changes in the plan of operation which affect the services to clients shall be subject to licensing agency approval and shall be reported as specified in Section 82061, Reporting Requirements


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview the licensee did not comply with the section cited above in the staff (4) and 3 clients from facility Alive east county (075600047) is using Garden Brentwood facility without informing Oakland Regional office which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2021
Plan of Correction
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Program coordinator need to submit a new plan of operation to LPA on 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: 09/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2021


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