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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200220
Report Date: 09/01/2022
Date Signed: 09/01/2022 12:10:45 PM

Document Has Been Signed on 09/01/2022 12:10 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: 12DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Ciara Vasquez, Program coordinator TIME COMPLETED:
12:25 PM
NARRATIVE
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On 9/1/2022 at around 10:10 AM, Licensing Program Analyst (LPA) L. Ibo conducted an infection control annual inspection and explained the purpose of the visit with S2. LPA called Ciara Vasquez Program Coordinator and informed her the purpose of the visit. At around 11:00AM, Ciara Vasquez arrived at the facility. 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. 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.



LPA observed the following:

· LPA observed that food storage (fridge) for the clients is stained with food particles

· Facility needs trash bin with lid at the staff room – technical assistance provided. S1 agreed to provide trash bin with lid for the staff.

· Facility do not have proof of covid19 training.

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.



Deficiencies and plan and proof of corrections were discussed with Ciara Vasquez.
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: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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 2
Document Has Been Signed on 09/01/2022 12:10 PM - It Cannot Be Edited


Created By: Leslie Ibo On 09/01/2022 at 11:45 AM
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: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065(f)(5)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (5) Recognition of early signs of illness and the need for professional assistance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above in, licensee failed to prove proof of training that all staff receive covid19 training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2022
Plan of Correction
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Facility staff (S2) agreed to train all staff, send proof of training and topics to CCLD office by POC date.
Type B
Section Cited
CCR
80076(a)(17)

(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above, licensee failed to maintain the food storage area clean for clients in care , LPA observed facility freezer for clients was stained with food particles, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2022
Plan of Correction
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Facility staff agreed to clean food storage area (fridge), proof of correction (picture) need to be send to CCL office by POC date. Program Coordinator Ciara V. needs to provide staff training using the regulation cited above.
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: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
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